Healthcare Provider Details

I. General information

NPI: 1053347765
Provider Name (Legal Business Name): RUSSELL JON ORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: R. JON ORD M.D.

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S 900 E
SALT LAKE CITY UT
84102-2310
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-535-8185
  • Fax: 801-355-4011
Mailing address:
  • Phone: 801-535-8185
  • Fax: 801-355-4011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number157929-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: