Provider Demographics
NPI:1619558277
Name:FENN, PRASHANTH G (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANTH
Middle Name:G
Last Name:FENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S CHIPETA WAY RM 201
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1260
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:375 S CHIPETA WAY RM 201
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1260
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13509667-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine