Provider Demographics
NPI:1023390531
Name:CHURCH, ROBERT A (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DPM
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 30015, DEPT 380
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:801-505-5277
Mailing Address - Fax:801-505-5280
Practice Address - Street 1:24 S 1100 E STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1580
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8926321-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery