Provider Demographics
NPI:1720025281
Name:ABDULLA, ALAN R (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:R
Last Name:ABDULLA
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 1:4403 HARRISON BLVD
Mailing Address - Street 2:#3620
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:801-387-3525
Mailing Address - Fax:801-387-3530
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:#3620
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-387-3525
Practice Address - Fax:801-387-3530
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1575521205207RP1001X
UT1575571205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT26764692017Medicaid
UT000001484Medicare ID - Type Unspecified
UT26764692017Medicaid
D07403Medicare UPIN