Provider Demographics
NPI:1821293242
Name:BLACKHAM, JASON LEE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:BLACKHAM
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:801-387-2750
Mailing Address - Fax:801-387-2755
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 2400
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2750
Practice Address - Fax:801-387-2755
Is Sole Proprietor?:No
Enumeration Date:2007-06-16
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7216493-1205207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00685134OtherMEDICARE RAILROAD
UT000065341Medicare PIN