Provider Demographics
NPI:1154642791
Name:REDD, MATTHEW KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KENNETH
Last Name:REDD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6028 S RIDGELINE DR
Mailing Address - Street 2:STE 201
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6908
Mailing Address - Country:US
Mailing Address - Phone:801-475-5400
Mailing Address - Fax:801-475-8614
Practice Address - Street 1:6028 S RIDGELINE DR
Practice Address - Street 2:201
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6914
Practice Address - Country:US
Practice Address - Phone:801-475-5400
Practice Address - Fax:801-475-8614
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013012534207R00000X
UT5115898-1204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine