Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 157929-1205 | UT |
NPI | 1053347765 |
---|---|
Provider Name | Russell Jon Ord |
First Address | Salt Lake City, UT 84127-0128 |
Second Address | Salt Lake City, UT 84102-2310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2006 |
Last Update Date | 26/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D26501 | (02) |