Provider Demographics
NPI:1790962587
Name:BIGELOW, JEFFREY KIMBALL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KIMBALL
Last Name:BIGELOW
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-507-6470
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1129962084N0400X
UT8276300-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055456Medicare PIN