1154059343 NPI number — STODDARD FOOT & ANKLE

Table of content: (NPI 1154059343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154059343 NPI number — STODDARD FOOT & ANKLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STODDARD FOOT & ANKLE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1154059343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84010-6236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-505-0821
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPANISH FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84660-1146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-225-0961
Provider Business Practice Location Address Fax Number:
385-448-5058
Provider Enumeration Date:
08/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
STODDARD
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
VERNON
Authorized Official Title or Position:
DPM/OWNER
Authorized Official Telephone Number:
208-697-0786

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10805840-0501 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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