Provider Demographics
NPI:1154703841
Name:GILBERT, PRESTON MANGUM (DO)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:MANGUM
Last Name:GILBERT
Suffix:
Gender:M
Credentials:DO
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 1:1000 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2069
Practice Address - Country:US
Practice Address - Phone:435-893-0800
Practice Address - Fax:435-893-0805
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016028884207PE0004X, 208600000X
UT5541451-1204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services