Provider Demographics
NPI:1386650364
Name:SUNDIN, JON R (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:SUNDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NORTH CENTER ST
Mailing Address - Street 2:#800
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:8TH AVENUE AND C STREET
Practice Address - Street 2:LDS HOSPITAL
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT85-173234-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804075900Medicaid
NV002088710Medicaid
WY101832900Medicaid
UT53274OtherHEALTHY U
UT8597445OtherWORKERS COMP FUND
UT107006550101OtherIHC
UT13720OtherDESERET MUTUAL
UT2090168OtherUNITED HEALTHCARE
UT870545614SN1OtherEDUCATORS MUTUAL
UT1502954OtherUMWA
UT37824OtherPEHP
UTQM0000075886OtherALTIUS
AZ246092Medicaid
UTTPRA08820OtherMOLINA
AZ246092Medicaid
UT13720OtherDESERET MUTUAL
UT050009028Medicare ID - Type UnspecifiedRAILROAD MEDICARE