Provider Demographics
NPI:1093081101
Name:UTAH PODIATRY GROUP PC
Entity type:Organization
Organization Name:UTAH PODIATRY GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-505-5277
Mailing Address - Street 1:PO BOX 30015 DEPT 380
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130
Mailing Address - Country:US
Mailing Address - Phone:801-505-5277
Mailing Address - Fax:801-505-5280
Practice Address - Street 1:24 S 1100 E STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1580
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH PODIATRY GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-23
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063660Medicare PIN