Provider Demographics
NPI:1558772533
Name:WHITAKER, JONATHAN TAYLOR (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TAYLOR
Last Name:WHITAKER
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7295
Practice Address - Country:US
Practice Address - Phone:801-507-4384
Practice Address - Fax:801-507-4398
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1023207R00000X
UT13716859-1204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine