Provider Demographics
NPI:1376651448
Name:ALLEN, C PRESTON (MD)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:PRESTON
Last Name:ALLEN
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-786-7500
Mailing Address - Fax:
Practice Address - Street 1:2400 NORTH WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:N OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-786-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT983627191205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1548202096Medicaid
005528129Medicare PIN
005509325Medicare PIN
UT1548202096Medicaid
005531310Medicare PIN
000063129Medicare PIN