Provider Demographics
NPI:1013902592
Name:FLANAGAN, DEIDRE A (MD)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:A
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2185
Mailing Address - Country:US
Mailing Address - Phone:435-719-3500
Mailing Address - Fax:
Practice Address - Street 1:450 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2185
Practice Address - Country:US
Practice Address - Phone:435-719-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40899208600000X
UT12793568-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32544100Medicaid
UT1013902592Medicaid
WI032071018Medicare PIN
WI030245300Medicare PIN