Provider Demographics
NPI:1710085261
Name:AUSTAD, THOMAS R (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:AUSTAD
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 1:1885 WEST 4400 SOUTH
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067
Mailing Address - Country:US
Mailing Address - Phone:801-731-3833
Mailing Address - Fax:801-731-4561
Practice Address - Street 1:1885 WEST 4400 SOUTH
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067
Practice Address - Country:US
Practice Address - Phone:801-731-3833
Practice Address - Fax:801-731-4561
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1026230501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
870341157OtherTAX ID
756480226OtherRR MEDICARE
756480226OtherRR MEDICARE
T77924Medicare UPIN