Healthcare Provider Details

I. General information

NPI: 1982661344
Provider Name (Legal Business Name): JEAN F BOTHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST STE 210
MURRAY UT
84107-5718
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3380
  • Fax: 801-507-8343
Mailing address:
  • Phone: 801-507-3380
  • Fax: 801-507-8343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12742339-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number12742339-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number22313
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: