Healthcare Provider Details

I. General information

NPI: 1710955745
Provider Name (Legal Business Name): FLEGAL FOOT & ANKLE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E 3900 S SUITE 108
SALT LAKE CITY UT
84107-2525
US

IV. Provider business mailing address

740 E 3900 S SUITE 108
SALT LAKE CITY UT
84107-2525
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-3113
  • Fax:
Mailing address:
  • Phone: 801-266-3113
  • Fax: 801-266-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number102232-0501
License Number StateUT

VIII. Authorized Official

Name: DR. DOUGLAS CLARK FLEGAL
Title or Position: MANAGER
Credential: DPM
Phone: 801-266-3113