Provider Demographics
NPI:1053392613
Name:POPE, RICHARD JACK (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JACK
Last Name:POPE
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 1:380 N 200 W
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7079
Mailing Address - Country:US
Mailing Address - Phone:801-298-1300
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:630 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-299-2200
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT165029-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT06400Medicaid
UT351118OtherDESERET MUTUAL BENEFITS ADMINISTRATORS
UT300083845OtherRAILROAD MEDICARE
UTU000072722Medicare PIN
UT300083845OtherRAILROAD MEDICARE
D20195Medicare UPIN