Healthcare Provider Details

I. General information

NPI: 1225201148
Provider Name (Legal Business Name): RODNEY GILLMAN JAY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

450 E MAIN ST
REXBURG ID
83440-2048
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2292
  • Fax:
Mailing address:
  • Phone: 208-356-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberM-12527
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5298339-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number5298339-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: