Provider Demographics
NPI:1598205494
Name:UTAH PODIATRY GROUP PC
Entity Type:Organization
Organization Name:UTAH PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-505-0821
Mailing Address - Street 1:PO BOX 30015
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:801-451-6060
Mailing Address - Fax:801-797-9154
Practice Address - Street 1:440 MEDICAL DR
Practice Address - Street 2:STE 1
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4950
Practice Address - Country:US
Practice Address - Phone:801-295-5070
Practice Address - Fax:801-774-0735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8926321-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063660OtherMEDICARE PIN
UT6152070010OtherDME PTAN