Provider Demographics
NPI:1083817944
Name:BLAINE F. BIRD, O.D., P.C.
Entity Type:Organization
Organization Name:BLAINE F. BIRD, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-374-2220
Mailing Address - Street 1:2255 N UNIVERSITY PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-7505
Mailing Address - Country:US
Mailing Address - Phone:801-374-2220
Mailing Address - Fax:801-373-5439
Practice Address - Street 1:2255 N UNIVERSITY PKWY
Practice Address - Street 2:SUITE #1
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1588
Practice Address - Country:US
Practice Address - Phone:801-374-2220
Practice Address - Fax:801-373-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1145549934332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1871581652OtherBLUE CROSS BLUE SHIELD
UT529961264004Medicaid
UTU32943Medicare UPIN
UT0967400001Medicare NSC