Healthcare Provider Details

I. General information

NPI: 1104895507
Provider Name (Legal Business Name): JESSE N HUNSAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N 1100 E
AMERICAN FORK UT
84003-2952
US

IV. Provider business mailing address

12 N 1100 E
AMERICAN FORK UT
84003-2952
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-9627
  • Fax: 801-763-0216
Mailing address:
  • Phone: 801-756-9627
  • Fax: 801-763-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number167725-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: