Provider Demographics
NPI:1619498375
Name:DEGN, NATHAN GLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:GLEN
Last Name:DEGN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 E 400 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2928
Mailing Address - Country:US
Mailing Address - Phone:801-328-2020
Mailing Address - Fax:801-363-2201
Practice Address - Street 1:849 E 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2928
Practice Address - Country:US
Practice Address - Phone:801-328-2020
Practice Address - Fax:801-328-2020
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10419932-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist