Dermatology Center of Salt Lake Inc.

Primary specialty

SpecialistTaxonomy code 174400000X

License

266561-1205 Issued in UT

Legal business name

DERMATOLOGY CENTER OF SALT LAKE INC.

Practice address

7396 Union Park Ave
#201
Midvale, UT 84047-6700

Phone

(801) 567-1400

Fax

(801) 567-1777

NPI assigned

Mar 29, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joseph D Jensen, MDNPI 1740281500

Title

MD/Owner

Phone

(801) 567-1400

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in UT

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Joseph Dean Jensen, MD

  • Specialist
  • Midvale, UT
  • NPI 1740281500
  Medicare reassignment Care Compare group Authorized official
• Keri L Holyoak, PA

  • Physician Assistant
  • Midvale, UT
  • NPI 1578578357
  Medicare reassignment Care Compare group
• Kirk Ronald Stephens, PA-C

  • Dermatology Physician
  • Midvale, UT
  • NPI 1992221980
  Medicare reassignment Care Compare group
• McKenzie Tonks, PA-C

  • Physician Assistant
  • Midvale, UT
  • NPI 1619698750
  NPD
• Katrina Reagan Lynch, PA-C

  • Physician Assistant
  • Killeen, TX
  • NPI 1154337863
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1143590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1555286400000",
    "number": "1689635799",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7396 UNION PARK AVE",
            "address_2": "#201",
            "city": "MIDVALE",
            "state": "UT",
            "postal_code": "840476700",
            "telephone_number": "801-567-1400",
            "fax_number": "801-567-1777"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7396 UNION PARK AVE",
            "address_2": "#201",
            "city": "MIDVALE",
            "state": "UT",
            "postal_code": "840476700",
            "telephone_number": "801-567-1400",
            "fax_number": "801-567-1777"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY CENTER OF SALT LAKE INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-29",
        "last_updated": "2019-04-15",
        "status": "A",
        "authorized_official_last_name": "JENSEN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "801-567-1400",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "UT",
            "license": "266561-1205",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ALTIUS",
            "identifier": "QM0000046926",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "528986681031",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "52898668108001",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IHC",
            "identifier": "107007222102",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Specialist in Midvale, UT
• Providers in Midvale, UT by specialty
• Specialist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.