Provider Demographics
NPI:1679847784
Name:JON W AHLSTROM MD PC
Entity Type:Organization
Organization Name:JON W AHLSTROM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:W
Authorized Official - Last Name:AHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-753-1545
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:STE I
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-753-1545
Mailing Address - Fax:435-753-3153
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:STE I
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-753-1545
Practice Address - Fax:435-753-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4918766-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty