Provider Demographics
NPI:1497168272
Name:AIDA, JARED TAKESHI (DO)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:TAKESHI
Last Name:AIDA
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 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S STE 4050
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1264
Practice Address - Country:US
Practice Address - Phone:801-262-8486
Practice Address - Fax:801-284-8699
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT123456-12052081S0010X, 208100000X
DCDO034752208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12573316-1204OtherLICENSE