MEDICARE: SHEBA JOHN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0002X	Adult Congenital Heart Disease Physician	12236679-1205	UT
2	2080P0202X	Pediatric Cardiology Physician	12236679-1205	UT

General Provider Information

NPI Number	:	1558781674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEBA JOHN M.D.

Provider Business Mailing Address
First Line	:	30 N 1900 E RM 3C444
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2501
Country	:	US
Telephone Number	:	801-587-1771
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N 1900 E RM 3C444
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2501
Country	:	US
Telephone Number	:	801-587-1771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	10/22/2023

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