Provider Demographics
NPI:1750794533
Name:SCOTT HUMPHERYS, DPM INC
Entity type:Organization
Organization Name:SCOTT HUMPHERYS, DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:HUMPHERYS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-225-3095
Mailing Address - Street 1:368 N 780 E
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-2519
Mailing Address - Country:US
Mailing Address - Phone:801-225-3095
Mailing Address - Fax:801-377-2426
Practice Address - Street 1:1355 N. UNIVERSITY AVE
Practice Address - Street 2:#125
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2722
Practice Address - Country:US
Practice Address - Phone:801-225-3095
Practice Address - Fax:801-377-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326796-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528292703007Medicaid
UT528292703007Medicaid