Provider Demographics
NPI:1144622234
Name:SALT LAKE RETINA, LLC
Entity Type:Organization
Organization Name:SALT LAKE RETINA, LLC
Other - Org Name:SALT LAKE RETINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEHR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-260-0034
Mailing Address - Street 1:3855 W 7800 S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5560
Mailing Address - Country:US
Mailing Address - Phone:801-260-0034
Mailing Address - Fax:801-260-0035
Practice Address - Street 1:3855 W 7800 S
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5560
Practice Address - Country:US
Practice Address - Phone:801-260-0034
Practice Address - Fax:801-260-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5934492-1205207W00000X
207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1508052234Medicaid
UT1508052234Medicaid
UTH81665Medicare UPIN