Healthcare Provider Details

I. General information

NPI: 1194580852
Provider Name (Legal Business Name): JORDAN VALLEY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 W 7000 S STE 202
WEST JORDAN UT
84084-3556
US

IV. Provider business mailing address

1561 W 7000 S STE 202
WEST JORDAN UT
84084-3556
US

V. Phone/Fax

Practice location:
  • Phone: 801-569-8344
  • Fax: 801-569-9150
Mailing address:
  • Phone: 801-569-8344
  • Fax: 801-569-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TAZEEM A AIZAD
Title or Position: PRESIDENT
Credential: MD
Phone: 801-557-7546