1730165572 NPI number — NATHAN W DAVIS D.P.M.

Table of content: NATHAN W DAVIS D.P.M. (NPI 1730165572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730165572 NPI number — NATHAN W DAVIS D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
NATHAN
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730165572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 MYRTLE AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-4833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-743-2909
Provider Business Mailing Address Fax Number:
801-288-9505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 MYRTLE AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-4833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-743-2909
Provider Business Practice Location Address Fax Number:
801-288-9505
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  49208910501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 123401800 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 49208910503001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM000061991 . This is a "ALTUIS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2700110 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 002189004 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00057743 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 731650218 . This is a "COMMERCIAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 731650218DAV . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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