Provider Demographics
NPI:1902365216
Name:COBURN, KENDELL PORTER (DO)
Entity Type:Individual
Prefix:
First Name:KENDELL
Middle Name:PORTER
Last Name:COBURN
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 1:425 E 5350 S STE 103
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6901
Mailing Address - Country:US
Mailing Address - Phone:385-298-0818
Mailing Address - Fax:801-205-4354
Practice Address - Street 1:425 E 5350 S STE 103
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6901
Practice Address - Country:US
Practice Address - Phone:385-298-0818
Practice Address - Fax:801-205-4354
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-RES-LIC-77254207R00000X
390200000X
UT12813168-1204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program