Healthcare Provider Details

I. General information

NPI: 1730165572
Provider Name (Legal Business Name): NATHAN W DAVIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 05/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MYRTLE AVE SUITE 201
MURRAY UT
84107-4833
US

IV. Provider business mailing address

154 MYRTLE AVE SUITE 201
MURRAY UT
84107-4833
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:
Title or Position:
Credential:
Phone: