Provider Demographics
NPI:1952610651
Name:JOHN D. UTLEY, D.P.M. PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JOHN D. UTLEY, D.P.M. PROFESSIONAL CORPORATION
Other - Org Name:DESERT FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:UTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-243-7333
Mailing Address - Street 1:8551 W LAKE MEAD BLVD
Mailing Address - Street 2:STE #230
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7642
Mailing Address - Country:US
Mailing Address - Phone:702-243-7333
Mailing Address - Fax:702-243-4800
Practice Address - Street 1:8551 W LAKE MEAD BLVD
Practice Address - Street 2:STE #230
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7642
Practice Address - Country:US
Practice Address - Phone:702-243-7333
Practice Address - Fax:702-243-4800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9713261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2102004Medicaid
NV1225390001Medicare NSC
NV2102004Medicaid