Provider Demographics
NPI:1245349042
Name:PRIBBLE, CHARLES G (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:PRIBBLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-993-9551
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173715-1205207L00000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT002085560OtherFIRST HEALTH
UT174281OtherDESERET MUTUAL
WY105131800Medicaid
UT870280408PR2OtherEDUCATORS MUTUAL
UT29927OtherPEHP
UTPR00809OtherMOLINA
UTQM0000049539OtherALTIUS
UT107006307101OtherIHC
UT2000040OtherUNITED HEALTHCARE
MT401765Medicaid
ID002967300Medicaid
UT8920OtherHEALTHY U