Healthcare Provider Details

I. General information

NPI: 1679763494
Provider Name (Legal Business Name): NATHAN W DAVIS DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MYRTLE AVE SUITE 201
MURRAY UT
84107-4849
US

IV. Provider business mailing address

154 MYRTLE AVE SUITE 201
MURRAY UT
84107-4849
US

V. Phone/Fax

Practice location:
  • Phone: 801-743-2909
  • Fax: 801-288-9505
Mailing address:
  • Phone: 801-743-2909
  • Fax: 801-288-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number49208910501
License Number StateUT

VIII. Authorized Official

Name: THIA HAMBLIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-743-2909