Provider Demographics
NPI:1023242815
Name:STODDART, JEREMY ROYLE (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROYLE
Last Name:STODDART
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 1:7676 W LAMPLIGHTER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-2059
Mailing Address - Country:US
Mailing Address - Phone:801-390-4618
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:UNIVERSITY HOSPITAL,
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-11662084P0800X, 390200000X
390200000X
IDM-118972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1023242815Medicaid
ID20003433Medicare PIN
ID20003432Medicare PIN
ID20003430Medicare PIN
ID20003429Medicare PIN
ID20003431Medicare PIN