Provider Demographics
NPI:1881862076
Name:KENT B MCDONALD M.D PERFFESIONAL
Entity Type:Organization
Organization Name:KENT B MCDONALD M.D PERFFESIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-2814
Mailing Address - Street 1:515 S 300 E
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3900
Mailing Address - Country:US
Mailing Address - Phone:435-628-2814
Mailing Address - Fax:435-674-7112
Practice Address - Street 1:515 S 300 E
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3900
Practice Address - Country:US
Practice Address - Phone:435-628-2814
Practice Address - Fax:435-674-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT06469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529647916001Medicaid
UT529647916001Medicaid
UT000012518Medicare PIN