Provider Demographics
NPI:1447217740
Name:FANG, JAMES C
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:FANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:DEACON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 413033
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-213-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77319207RC0000X
OH35-088454207RC0000X
UT8555716-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000224446OtherUNISON
OH000000539492OtherANTHEM
OH267792Medicaid
OH743259OtherBUCKEYE
OH363520OtherWELLCARE
OHP00449274OtherRAILROAD MEDICARE
OH5198667OtherAETNA
OH743259OtherBUCKEYE