Provider Demographics
NPI:1750478707
Name:CARLISLE, JAMES GERALD (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GERALD
Last Name:CARLISLE
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 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5617957-12052085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1750478707Medicaid
UT107031591105OtherSELECTHEALTH
UT56179571211001OtherBCBSUT
UTP00808365OtherRR MEDICARE
UT847597OtherDMBA
UTP00808370OtherRR MEDICARE
UT56179571210001OtherBCBSUT
UT847597OtherDMBA
UT56179571210001OtherBCBSUT
UTP00808365OtherRR MEDICARE