Provider Demographics
NPI:1891742508
Name:PUGH, BRENTEN CLARK (MD)
Entity Type:Individual
Prefix:
First Name:BRENTEN
Middle Name:CLARK
Last Name:PUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 572528
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-2528
Mailing Address - Country:US
Mailing Address - Phone:801-747-7279
Mailing Address - Fax:801-747-7237
Practice Address - Street 1:7478 CAMPUS VIEW DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1966
Practice Address - Country:US
Practice Address - Phone:801-280-7774
Practice Address - Fax:801-748-2790
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5054030-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH56982Medicare UPIN