Provider Demographics
NPI:1124121934
Name:WALLENTINE, JEFFREY M (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:WALLENTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 121
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:801-812-5401
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT356423-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107008449102OtherIHC
UT68080OtherPEHP
UT09-00180OtherUTAH HEALTHCARE
UT344490OtherDMBA
UT870281028000Medicaid
UTQM000056640OtherALTIUS
UT200045124OtherPALMETTO
UT870281028WALOtherEMIA
UT09-00180OtherUTAH HEALTHCARE
UT005502565Medicare PIN
UT870281028WALOtherEMIA
UT870281028000Medicaid