Healthcare Provider Details

I. General information

NPI: 1588043871
Provider Name (Legal Business Name): JORDAN RUSSELL ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JORDAN ESSARY

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 09/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 E MURRAY HOLLADAY RD STE 207
HOLLADAY UT
84117-5093
US

IV. Provider business mailing address

999 E MURRAY HOLLADAY RD STE 207
HOLLADAY UT
84117-5093
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-2584
  • Fax: 801-262-1168
Mailing address:
  • Phone: 801-268-2584
  • Fax: 801-262-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9897039-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: