Provider Demographics
NPI:1467891903
Name:OLDHAM, JEDIDIAH DUNBAR (DO)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:DUNBAR
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:97 PROFESSIONAL WAY STE 2
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1680
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-4107
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020701208600000X
MT58976390200000X
UT11197222-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program