Healthcare Provider Details

I. General information

NPI: 1619554110
Provider Name (Legal Business Name): JESSE DEWEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 N MAIN ST
RICHFIELD UT
84701-1840
US

IV. Provider business mailing address

861 N MAIN ST
RICHFIELD UT
84701-1840
US

V. Phone/Fax

Practice location:
  • Phone: 435-558-7031
  • Fax: 435-558-7031
Mailing address:
  • Phone: 360-739-4467
  • Fax: 435-558-7031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number14207082-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number14207082-1204
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number14207082-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: