Provider Demographics
NPI:1063680668
Name:FLEGAL, DOUGLAS CLARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CLARK
Last Name:FLEGAL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:740 E 3900 S
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2181
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:801-266-5633
Practice Address - Street 1:740 E 3900 S
Practice Address - Street 2:SUITE 108
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2181
Practice Address - Country:US
Practice Address - Phone:801-266-3113
Practice Address - Fax:801-266-5633
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102232-0501213EP1101X, 213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT77918Medicare UPIN