Basic Information
| Provider Information | |||||||||
| NPI: | 1891742508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGH | ||||||||
| FirstName: | BRENTEN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 572528 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841572528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017477279 | ||||||||
| FaxNumber: | 8017477237 | ||||||||
| Practice Location | |||||||||
| Address1: | 7478 CAMPUS VIEW DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840841966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012807774 | ||||||||
| FaxNumber: | 8017482790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 08/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5054030-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.