Provider Demographics
NPI:1164421798
Name:KIRKHAM, JASON ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANTHONY
Last Name:KIRKHAM
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:PO BOX 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5827923-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT58279231203001OtherBCBSUT
ID807205500Medicaid
UTP00651539OtherRR MEDICARE
NV100505947Medicaid
UTD6039Medicaid
WY120831400Medicaid
UTP00224687OtherRR MEDICARE
UT58279231200001OtherBCBSUT
ID807205500Medicaid
UT58279231200001OtherBCBSUT
NV100505947Medicaid
UTI06926Medicare UPIN
UT005790126Medicare PIN