Provider Demographics
NPI:1285627455
Name:AZARCON, JOSE JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:AZARCON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:STE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6923
Mailing Address - Country:US
Mailing Address - Phone:801-365-1032
Mailing Address - Fax:801-365-1036
Practice Address - Street 1:6360 S 3000 E
Practice Address - Street 2:STE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6923
Practice Address - Country:US
Practice Address - Phone:801-365-1032
Practice Address - Fax:801-365-1036
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT985812-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
498828Medicare ID - Type Unspecified
G08559Medicare UPIN
CO01329382Medicaid