Provider Demographics
NPI:1699876987
Name:STARR, JEREMY C (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:C
Last Name:STARR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W 100 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9826
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:
Practice Address - Street 1:1515 N 400 E STE 104
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7595
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6842A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118894100Medicaid
WY313768OtherBLUE CROSS/BLUE SHIELD
WYH93760Medicare UPIN
WY118894100Medicaid