Healthcare Provider Details

I. General information

NPI: 1114224805
Provider Name (Legal Business Name): WASATCH PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2011
Last Update Date: 07/13/2025
Certification Date: 07/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1679 SHADOW VALLEY DR
OGDEN UT
84403-4626
US

IV. Provider business mailing address

PO BOX 150383
OGDEN UT
84415-0383
US

V. Phone/Fax

Practice location:
  • Phone: 801-430-8406
  • Fax: 801-393-6092
Mailing address:
  • Phone: 801-430-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number7259622-0501
License Number StateUT

VIII. Authorized Official

Name: SUSAN AGRES
Title or Position: OWNER
Credential: DPM
Phone: 801-430-8406