Basic Information
| Provider Information | |||||||||
| NPI: | 1528186954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RETINA AND VITREOUS SURGEONS OF UTAH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577704 | ||||||||
| FaxNumber: | 8013577424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577704 | ||||||||
| FaxNumber: | 8013577424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARVER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OR CEO | ||||||||
| AuthorizedOfficialTelephone: | 8013577704 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 165213-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.