Provider Demographics
NPI:1851321442
Name:PERRY, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:PERRY
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 17541
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-0541
Mailing Address - Country:US
Mailing Address - Phone:801-232-1633
Mailing Address - Fax:
Practice Address - Street 1:910 W 5TH AVE STE 900
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2948
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10502207R00000X, 207RC0000X, 207RI0011X
WAMD60421229207RC0000X, 207RI0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000098585OtherBLUE CROSS BLUE SHIELD MT
MT1851321442Medicaid
MT1851321442Medicaid
MT000085424Medicare UPIN