Provider Demographics
NPI:1275576027
Name:KIRSTEIN, JUDITH L (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:KIRSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8846 S REDWOOD RD
Mailing Address - Street 2:STE E121
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9334
Mailing Address - Country:US
Mailing Address - Phone:801-569-1999
Mailing Address - Fax:801-569-2001
Practice Address - Street 1:8846 S REDWOOD RD
Practice Address - Street 2:STE E121
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9334
Practice Address - Country:US
Practice Address - Phone:801-569-1999
Practice Address - Fax:801-569-2001
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164009-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT06179Medicaid
UT1164672770Medicaid
P00661779Medicare PIN
UT000064936Medicare PIN
UT1164672770Medicaid
UT000001273Medicare ID - Type Unspecified