Provider Demographics
NPI:1407944457
Name:RENDO, JACQUELINE A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:RENDO
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-535-8163
Mailing Address - Fax:801-355-4011
Practice Address - Street 1:333 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:801-535-8163
Practice Address - Fax:801-355-4011
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30914207V00000X
UT7583334-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS797277Medicaid
AZAZ0741230OtherBCBS
AZAZ0741230OtherBCBS
AZ8HBQ43Medicare UPIN
AZH91778Medicare UPIN
UTU000072093Medicare PIN