MEDICARE: DR. JON W AHLSTROM 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	207V00000X	Obstetrics & Gynecology Physician	CP209732	OR
2	207V00000X	Obstetrics & Gynecology Physician	49187661205	UT

General Provider Information

NPI Number	:	1437146065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON W AHLSTROM MD

Provider Business Mailing Address
First Line	:	550 E 1400 N
Second Line	:	SUITE I
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-753-1545
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 E 1400 N
Second Line	:	SUITE I
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-753-1545
Fax Number	:

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	04/18/2022

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