Provider Demographics
NPI:1457452476
Name:MYTYCH, JOHN J (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MYTYCH
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 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:962 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5087
Practice Address - Country:US
Practice Address - Phone:801-373-2499
Practice Address - Fax:801-373-5200
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10140276-0501213ES0103X
IL016005082213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10140276-0501OtherMEDICAL LICENSE
UTQ00214425OtherRR MEDICARE
UTU00011270OtherMEDICARE PTAN
ILK16809Medicare ID - Type Unspecified