Provider Demographics
NPI:1700369014
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
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:801-505-5277
Mailing Address - Street 1:24 S 1100 E STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1580
Mailing Address - Country:US
Mailing Address - Phone:801-505-5277
Mailing Address - Fax:801-505-5280
Practice Address - Street 1:6321 S REDWOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6799
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT106339-0501OtherLICENSE