| National Provider Identifier [NPI]: | 1255434296 |
| Last Name Of The Provider | JACK |
| First Name Of The Provider | DAVID |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 11760 S 700 E STE 111 |
| Street Address 2 Of The Provider | |
| City Of The Provider | DRAPER |
| Zip Code Of The Provider | 840206605 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 72 |
| Number Of Services | 1937 |
| Number Of Medicare Beneficiaries | 262 |
| Total Submitted Charge Amount | 238296 |
| Total Medicare Allowed Amount | 99390.39 |
| Total Medicare Payment Amount | 69368.63 |
| Total Medicare Standardized Payment Amount | 72153.82 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 14 |
| Number Of Drug Services | 809 |
| Number Of Medicare Beneficiaries With Drug Services | 76 |
| Total Drug Submitted ChargeAmount | 45053 |
| Total Drug Medicare AllowedAmount | 9802.06 |
| Total Drug Medicare PaymentAmount | 7795.27 |
| Total Drug Medicare Standardized Payment Amount | 7795.27 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 58 |
| Number Of Medical Services | 1128 |
| Number Of Medicare Beneficiaries With Medical Services | 262 |
| Total Medical Submitted Charge Amount | 193243 |
| Total Medical Medicare Allowed Amount | 89588.33 |
| Total Medical Medicare Payment Amount | 61573.36 |
| Total Medical Medicare Standardized Payment Amount | 64358.55 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 14 |
| Number Of Beneficiaries Age 65 to 74 | 137 |
| Number Of Beneficiaries Age 75 to 84 | 77 |
| Number Of Beneficiaries Age Greater 84 | 34 |
| Number Of Female Beneficiaries | 135 |
| Number Of Male Beneficiaries | 127 |
| Number Of Non Hispanic White Beneficiaries | 247 |
| Number Of Black or African American Beneficiaries | 0 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 58 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0484 |