MEDICARE: MR. JERRY WILLIAM HUSSONG DDS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZH0000X	Hematology (Pathology) Physician	9291	NV
2	207ZH0000X	Hematology (Pathology) Physician	G86484	CA
3	207ZH0000X	Hematology (Pathology) Physician	3403921205	UT
4	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	9291	NV
5	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	G86484	CA
6	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	3403921205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346201209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY WILLIAM HUSSONG DDS MD

Provider Business Mailing Address
First Line	:	500 S CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1221
Country	:	US
Telephone Number	:	801-583-2787
Fax Number	:	801-584-5141

Provider Business Practice Location Address
First Line	:	500 S CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1221
Country	:	US
Telephone Number	:	801-583-2787
Fax Number	:	801-584-5141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	10/29/2013

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