Provider Demographics
NPI:1679763494
Name:NATHAN W DAVIS DPM PC
Entity type:Organization
Organization Name:NATHAN W DAVIS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-743-2909
Mailing Address - Street 1:154 MYRTLE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4849
Mailing Address - Country:US
Mailing Address - Phone:801-743-2909
Mailing Address - Fax:801-288-9505
Practice Address - Street 1:154 MYRTLE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4849
Practice Address - Country:US
Practice Address - Phone:801-743-2909
Practice Address - Fax:801-288-9505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49208910501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT002189004OtherMEDICAID NEVADA
UT49208910503001OtherBLUE CROSS BLUE SHIELD
UT2700110OtherUNITED HEALTH CARE
UT418216001OtherCIGNA MEDICARE
UT123401800OtherUS DEPT OF LABOR
UT528271194007Medicaid
UTP00057743OtherRAILROAD MEDICARE
UTQM000061991OtherALTIUS
UT528271194007Medicaid
UT002189004OtherMEDICAID NEVADA
UT=========OtherCOMMERCIAL
UT418216001OtherCIGNA MEDICARE
UTP00057743OtherRAILROAD MEDICARE