Provider Demographics
NPI:1598733941
Name:PICKRON, THOMAS BARTLEY JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BARTLEY
Last Name:PICKRON
Suffix:JR
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 1:30 N 1900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-581-7124
Mailing Address - Fax:801-585-1520
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-7124
Practice Address - Fax:801-585-1520
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2017174400000X
UT93632391205208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175928401Medicaid
TX175928401Medicaid
TXI39174Medicare UPIN