Provider Demographics
NPI:1942261037
Name:MALLENDER, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MALLENDER
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180838-1205207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0022Medicaid
UTP00214602OtherRAILROAD
UTD0022Medicaid
UT$$$$$$$$$05001OtherBC/BS
UT$$$$$$$$$03001OtherBC/BS
UT$$$$$$$$$06001OtherBC/BS
UT$$$$$$$$$04001OtherBC/BS
UT$$$$$$$$$07001OtherBC/BS
UT$$$$$$$$$08001OtherBC/BS
UTD0022Medicaid
UT005568547Medicare ID - Type Unspecified630 MEDICAL DR, BOUNTIFUL
UT$$$$$$$$$09001OtherBC/BS
UTP00214602OtherRAILROAD
UT005568440Medicare ID - Type Unspecified3580 W 9000 S, W JORDAN
UT005567230Medicare ID - Type Unspecified5475 S 500 E, OGDEN
UT$$$$$$$$$07001OtherBC/BS
UTD0022Medicaid