MEDICARE: KENDELL PORTER COBURN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MED-RES-LIC-77254	MT
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207R00000X	Internal Medicine Physician	12813168-1204	UT

General Provider Information

NPI Number	:	1902365216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDELL PORTER COBURN DO

Provider Business Mailing Address
First Line	:	425 E 5350 S STE 103
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-6901
Country	:	US
Telephone Number	:	385-298-0818
Fax Number	:	801-205-4354

Provider Business Practice Location Address
First Line	:	425 E 5350 S STE 103
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-6901
Country	:	US
Telephone Number	:	385-298-0818
Fax Number	:	801-205-4354

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2019
Last Update Date	:	06/29/2022

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