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General NPI Number Information
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NPI Number | 1023242815
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Entity Type | Individual
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Provider Name | JEREMY ROYLE STODDART MD
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Gender | Male
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Dates
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Enumeration Date | 05/07/2009
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Last Update Date | 11/23/2021
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Provider Practice Location Address
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Address Line | 30 N 1900 E UNIVERSITY HOSPITAL,
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City | SLC
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State | UT
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Zip | 84132
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Country | US
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Telephone | 801-581-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 7676 W LAMPLIGHTER ST
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City | BOISE
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State | ID
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Zip | 83714-2059
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Country | US
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Telephone | 801-390-4618
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MR-1166
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | MR-1166
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | M-11897
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License Number State | ID
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