Provider Demographics
NPI:1093761264
Name:PEREZ TAMAYO, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:PEREZ TAMAYO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 N 200 W
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7079
Mailing Address - Country:US
Mailing Address - Phone:801-298-1300
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:380 N 200 W
Practice Address - Street 2:SUITE 209
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7079
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7197358-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10937612601001OtherBLUE CROSS AND BLUE SHIELD OF UTAH
UT107072555101OtherSELECTHEALTH
UT1093761264OtherUNIVERSITY OF UTAH HEALTH PLANS
UT10937612600001OtherBLUE CROSS AND BLUE SHIELD OF UTAH
IL036092616Medicaid
UTP00681087OtherRR MEDICARE
UTP00684779OtherRR MEDICARE
UT107072555102OtherSELECTHEALTH
UT1003172OtherDESERET MUTUAL BENEFIT ADMINISTRATORS
UT1003172OtherDESERET MUTUAL BENEFIT ADMINISTRATORS
UT107072555102OtherSELECTHEALTH
IL036092616Medicaid