Provider Demographics
NPI:1578520904
Name:HUFF, GLEN FORREST (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:FORREST
Last Name:HUFF
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 1:2380 N 400 E
Mailing Address - Street 2:STE C
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-753-7337
Mailing Address - Fax:
Practice Address - Street 1:2380 N 400 E
Practice Address - Street 2:STE C
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1749
Practice Address - Country:US
Practice Address - Phone:435-753-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3714601205208000000X
UT371460-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H09956Medicare UPIN