Provider Demographics
NPI:1215971759
Name:HEBDON, CARL KENT (MD, MS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:KENT
Last Name:HEBDON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 E MURRAY HOLLADAY RD
Mailing Address - Street 2:STE 209
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5142
Mailing Address - Country:US
Mailing Address - Phone:801-273-0306
Mailing Address - Fax:801-273-0317
Practice Address - Street 1:2040 E MURRAY HOLLADAY RD
Practice Address - Street 2:STE 209
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5142
Practice Address - Country:US
Practice Address - Phone:801-273-0306
Practice Address - Fax:801-237-0317
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160845-8905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid
UT$$$$$$$$$001Medicaid