Provider Demographics
NPI:1144200155
Name:FAWSON, LORELL B (DPM)
Entity Type:Individual
Prefix:
First Name:LORELL
Middle Name:B
Last Name:FAWSON
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 1:3590 HARRISON BLVD
Mailing Address - Street 2:G1
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-627-2122
Mailing Address - Fax:801-627-2125
Practice Address - Street 1:3590 HARRISON BLVD
Practice Address - Street 2:G1
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-627-2122
Practice Address - Fax:801-627-2125
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1030720501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT77940Medicare UPIN
UT5240980001Medicare NSC