Provider Demographics
NPI:1508979048
Name:UTLEY, JOHN DWIGHT (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DWIGHT
Last Name:UTLEY
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 1:8551 W LAKE MEAD BLVD
Mailing Address - Street 2:STE #230
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7642
Mailing Address - Country:US
Mailing Address - Phone:702-243-7333
Mailing Address - Fax:702-243-4800
Practice Address - Street 1:8551 W LAKE MEAD BLVD
Practice Address - Street 2:STE #230
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7642
Practice Address - Country:US
Practice Address - Phone:702-243-7333
Practice Address - Fax:702-243-4800
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9713213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1225390001OtherPTAN
NV2102004Medicaid
U68055Medicare UPIN
NV1225390001Medicare NSC
NVV30382Medicare ID - Type Unspecified