Basic Information
Provider Information | |||||||||
NPI: | 1154850477 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NAEGLE | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5546 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802175546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014753500 | ||||||||
FaxNumber: | 8014753494 | ||||||||
Practice Location | |||||||||
Address1: | 698 12TH ST | ||||||||
Address2: |   | ||||||||
City: | OGDEN | ||||||||
State: | UT | ||||||||
PostalCode: | 844046200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014753700 | ||||||||
FaxNumber: | 8014753701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2017 | ||||||||
LastUpdateDate: | 05/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R-10913 | IA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 70007041204 | UT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1154850477 | 05 | UT |   | MEDICAID |