Provider Demographics
NPI:1053560789
Name:AGRES, SUSAN JESPERSEN (DPM)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JESPERSEN
Last Name:AGRES
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 32ND ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-0902
Mailing Address - Country:US
Mailing Address - Phone:801-430-8406
Mailing Address - Fax:801-393-6092
Practice Address - Street 1:5275 ADAMS AVE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6748
Practice Address - Country:US
Practice Address - Phone:801-430-8406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004009213ES0131X
UT7259622-0504213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery