MEDICARE: FLEGAL FOOT & ANKLE CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	102232-0501	UT

General Provider Information

NPI Number	:	1710955745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLEGAL FOOT & ANKLE CLINIC, LLC

Provider Business Mailing Address
First Line	:	740 E 3900 S
Second Line	:	SUITE 108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2525
Country	:	US
Telephone Number	:	801-266-3113
Fax Number	:	801-266-5633

Provider Business Practice Location Address
First Line	:	740 E 3900 S
Second Line	:	SUITE 108
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2525
Country	:	US
Telephone Number	:	801-266-3113
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DOUGLAS CLARK FLEGAL
Credential	:	DPM
Telephone Number	:	801-266-3113

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	08/28/2012

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