Provider Demographics
NPI:1124447172
Name:SIKORA-KLAK, JAKUB (MD)
Entity type:Individual
Prefix:
First Name:JAKUB
Middle Name:
Last Name:SIKORA-KLAK
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 1:1160 E 3900 S STE 5000
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1275
Mailing Address - Country:US
Mailing Address - Phone:801-261-7479
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S STE 5000
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1275
Practice Address - Country:US
Practice Address - Phone:801-261-7479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12358040-1205207X00000X
390200000X
CAA139057207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS6740OtherTMB