Provider Demographics
NPI:1841346756
Name:JOLLES, CHRISTOPHER JESSE (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JESSE
Last Name:JOLLES
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 1:12391 S 4000 W
Mailing Address - Street 2:STE 208
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7015
Mailing Address - Country:US
Mailing Address - Phone:801-302-5360
Mailing Address - Fax:801-302-7898
Practice Address - Street 1:12391 S 4000 W
Practice Address - Street 2:STE 208
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7015
Practice Address - Country:US
Practice Address - Phone:801-302-5360
Practice Address - Fax:801-302-7898
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT167833-1205207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000061973Medicare PIN