Provider Demographics
NPI:1528445202
Name:ROOT, ERIC JONATHAN (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JONATHAN
Last Name:ROOT
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 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741
Practice Address - Country:US
Practice Address - Phone:435-644-4100
Practice Address - Fax:435-644-3366
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
UT10875819-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty