Provider Demographics
NPI:1003057894
Name:MCINTOSH, RENEE A (OD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 S STATE ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7133
Mailing Address - Country:US
Mailing Address - Phone:801-568-0200
Mailing Address - Fax:801-563-0200
Practice Address - Street 1:11820 S STATE ST
Practice Address - Street 2:STE. 200
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7133
Practice Address - Country:US
Practice Address - Phone:801-568-0200
Practice Address - Fax:801-563-0200
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47865699934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU82203Medicare UPIN