Provider Demographics
NPI:1194015693
Name:CHIDESTER, JEREMY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ROBERT
Last Name:CHIDESTER
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 1:1309 W SOUTH JORDAN PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9014
Mailing Address - Country:US
Mailing Address - Phone:801-839-5557
Mailing Address - Fax:801-770-4455
Practice Address - Street 1:1309 W SOUTH JORDAN PKWY STE 110
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9014
Practice Address - Country:US
Practice Address - Phone:801-839-5557
Practice Address - Fax:801-770-4455
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10668647-12052082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand