Provider Demographics
NPI:1437146065
Name:AHLSTROM, JON W (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:W
Last Name:AHLSTROM
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 1:550 E 1400 N
Mailing Address - Street 2:SUITE I
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-753-1545
Mailing Address - Fax:
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:SUITE I
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-753-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCP209732207V00000X
UT49187661205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH37391Medicare UPIN