Provider Demographics
NPI:1760528137
Name:DAVID B JACK MD PC
Entity Type:Organization
Organization Name:DAVID B JACK MD PC
Other - Org Name:LONE PEAK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-576-8855
Mailing Address - Street 1:11760 S 700 E STE 111
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6605
Mailing Address - Country:US
Mailing Address - Phone:801-576-8855
Mailing Address - Fax:801-576-9800
Practice Address - Street 1:11760 S 700 E STE 111
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6605
Practice Address - Country:US
Practice Address - Phone:801-576-8855
Practice Address - Fax:801-576-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057745Medicare PIN