Provider Demographics
NPI:1275639122
Name:NILSON, JAY TODD (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:TODD
Last Name:NILSON
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 1:10150 CENTENNIAL PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4123
Mailing Address - Country:US
Mailing Address - Phone:800-594-5736
Mailing Address - Fax:
Practice Address - Street 1:10150 CENTENNIAL PKWY STE 230
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4123
Practice Address - Country:US
Practice Address - Phone:800-594-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-83928207L00000X
UT366647-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7151OtherHEALTHY U
UT425650OtherDESERET MUTUAL
UTPRA02246OtherMOLINA
UT107008628103OtherIHC
UT66104OtherPEHP
UTQM0000054865OtherALTIUS
UT870666269JTNOtherEDUCATORS MUTUAL
UT190683600OtherUS DEPT OF LABOR
UTQM0000054865OtherALTIUS
UT870666269JTNOtherEDUCATORS MUTUAL
UTF63958Medicare UPIN