Provider Demographics
NPI:1578925137
Name:ALLEN, MATTHEW DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DOUGLAS
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E 1140 N STE B
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-5467
Mailing Address - Country:US
Mailing Address - Phone:801-407-6500
Mailing Address - Fax:801-407-6505
Practice Address - Street 1:41 E 1140 N STE B
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-5467
Practice Address - Country:US
Practice Address - Phone:801-407-6500
Practice Address - Fax:801-407-6505
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110548581204208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program