Provider Demographics
NPI:1982816351
Name:JIRICKO, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:JIRICKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PHIL
Other - Middle Name:
Other - Last Name:JIRICKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5375 SHOSHONE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-555-5555
Mailing Address - Fax:
Practice Address - Street 1:2400 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-786-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6283141-12052083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine