Provider Demographics
NPI:1316035942
Name:OBERG, JON C (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:C
Last Name:OBERG
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 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:2121 N 1700 W
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8803
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8151
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79243208600000X, 2086S0129X
UT6885624-1205208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G792430Medicaid
UT1316035942Medicaid
UT000067497Medicare PIN
00G792430Medicare ID - Type Unspecified
P00762933Medicare PIN
UT000068729Medicare PIN
UT1316035942Medicaid