Provider Demographics
NPI:1003820234
Name:FENTON, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FENTON
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:PO BOX 100253
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 E KIMBALLS LN STE 207
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5025
Practice Address - Country:US
Practice Address - Phone:801-576-2300
Practice Address - Fax:419-537-5600
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062570207X00000X, 207XX0005X
UT2606111205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0265449Medicaid
OH0265449Medicaid
OHF69832Medicare UPIN
OH4754190005Medicare NSC
OHFE0808245Medicare PIN