Provider Demographics
NPI:1083962245
Name:CHURCH, JEREMIAH V (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:V
Last Name:CHURCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 COUNTRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2200
Mailing Address - Country:US
Mailing Address - Phone:801-399-1149
Mailing Address - Fax:
Practice Address - Street 1:875 COUNTRY HILLS DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2200
Practice Address - Country:US
Practice Address - Phone:801-399-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5596291-9934207W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty