Provider Demographics
NPI:1700859907
Name:CHENWORTH, ERIC C (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:CHENWORTH
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 1:24 S 1100 E STE 201
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1554
Mailing Address - Country:US
Mailing Address - Phone:385-290-1289
Mailing Address - Fax:385-290-1290
Practice Address - Street 1:24 S 1100 E STE 201
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1554
Practice Address - Country:US
Practice Address - Phone:385-290-1289
Practice Address - Fax:385-290-1290
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46865207K00000X, 207R00000X
UT7666176-1204207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32024738Medicaid
COH95220Medicare UPIN
CO32024738Medicaid
CO301356Medicare PIN