Provider Demographics
NPI:1669479341
Name:JOB, JEFFREY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:JOB
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:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1108
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-77462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805523600Medicaid
WY119044000Medicaid
UT10985Medicaid
ID1144191Medicare PIN
UT005546906Medicare PIN
UT300106737Medicare PIN
IDP00334654Medicare PIN
WY119044000Medicaid