Healthcare Provider Details

I. General information

NPI: 1215432521
Provider Name (Legal Business Name): JIVATESH SINGH TUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 S STE 320
SALT LAKE CITY UT
84124-1350
US

IV. Provider business mailing address

1250 E 3900 S STE 320
SALT LAKE CITY UT
84124-1350
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-1621
  • Fax:
Mailing address:
  • Phone: 801-263-1621
  • Fax: 801-263-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number14282218-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61446781
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: