Provider Demographics
NPI:1417310483
Name:LAW, NATHAN WALTER (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WALTER
Last Name:LAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 W ANTELOPE DR STE 175
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1175
Mailing Address - Country:US
Mailing Address - Phone:801-773-2233
Mailing Address - Fax:801-773-2375
Practice Address - Street 1:1580 W ANTELOPE DR STE 175
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1175
Practice Address - Country:US
Practice Address - Phone:801-773-2233
Practice Address - Fax:801-773-2375
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11499132-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4006687Medicaid