Provider Demographics
NPI:1528006491
Name:WALL, JON T (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:T
Last Name:WALL
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 1:4624 HOLLADAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5206
Mailing Address - Country:US
Mailing Address - Phone:801-277-2682
Mailing Address - Fax:801-277-2980
Practice Address - Street 1:4624 HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5206
Practice Address - Country:US
Practice Address - Phone:801-277-2682
Practice Address - Fax:801-277-2980
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT76-159863-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000005441Medicare PIN
UTD07861Medicare UPIN