Provider Demographics
NPI:1063807485
Name:SALT LAKE FOOT AND ANKLE PLLC
Entity type:Organization
Organization Name:SALT LAKE FOOT AND ANKLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BIJAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-419-6206
Mailing Address - Street 1:315 W REED AVE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1492
Mailing Address - Country:US
Mailing Address - Phone:801-419-6206
Mailing Address - Fax:
Practice Address - Street 1:315 W REED AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-1492
Practice Address - Country:US
Practice Address - Phone:801-419-6206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345724-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty