Provider Demographics
NPI:1396927786
Name:CHARLES CANFIELD, MD, LLC
Entity type:Organization
Organization Name:CHARLES CANFIELD, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:OLIN
Authorized Official - Last Name:CANFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-602-4256
Mailing Address - Street 1:897 S 300 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6792
Mailing Address - Country:US
Mailing Address - Phone:801-602-4256
Mailing Address - Fax:
Practice Address - Street 1:897 S 300 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6792
Practice Address - Country:US
Practice Address - Phone:801-602-4256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTA77962Medicare UPIN
UT000057517Medicare PIN