Provider Demographics
NPI:1699734079
Name:SONKENS, JERRY W (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:SONKENS
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 1:4000 S 700 E
Mailing Address - Street 2:STE 10
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2180
Mailing Address - Country:US
Mailing Address - Phone:801-268-4141
Mailing Address - Fax:801-261-8609
Practice Address - Street 1:4000 S 700 E
Practice Address - Street 2:STE 10
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84107-2180
Practice Address - Country:US
Practice Address - Phone:801-268-4141
Practice Address - Fax:801-261-8609
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159823-1205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870354540001Medicaid
UTC63913Medicare UPIN
UT005791701Medicare ID - Type Unspecified