Provider Demographics
NPI:1235266776
Name:LEGACY MEDICAL PC
Entity Type:Organization
Organization Name:LEGACY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OREN
Authorized Official - Middle Name:CLARON
Authorized Official - Last Name:ALLDREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-288-0067
Mailing Address - Street 1:4400 S 700 E STE 140
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3053
Mailing Address - Country:US
Mailing Address - Phone:801-288-0067
Mailing Address - Fax:801-288-0067
Practice Address - Street 1:4400 S 700 E STE 140
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3053
Practice Address - Country:US
Practice Address - Phone:801-288-0067
Practice Address - Fax:801-288-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT155564-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD99474Medicare UPIN