Provider Demographics
NPI:1205833050
Name:PENKA, CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:PENKA
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 1:4403 HARRISON BLVD
Mailing Address - Street 2:SUITE 1815
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-6520
Mailing Address - Fax:801-387-6557
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 1815
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-6520
Practice Address - Fax:801-387-6557
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT811667271205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD35880Medicare UPIN