Provider Demographics
NPI:1750586624
Name:CHRISTOPHER F. PENKA, M.D., P.A., INC.
Entity type:Organization
Organization Name:CHRISTOPHER F. PENKA, M.D., P.A., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:F
Authorized Official - Last Name:PENKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-387-6520
Mailing Address - Street 1:4403 HARRISON BLVD STE 1815
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-6520
Mailing Address - Fax:801-387-6557
Practice Address - Street 1:4403 HARRISON BLVD STE 1815
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-6520
Practice Address - Fax:801-387-6557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT811667271205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT556809063000Medicaid
UT556809063000Medicaid