Basic Information
| Provider Information | |||||||||
| NPI: | 1154642791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Practice Location | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | 201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2013012534 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 5115898-1204 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.