Provider Demographics
NPI:1184686768
Name:ROLLINS, LYMAN VAL (MD)
Entity Type:Individual
Prefix:DR
First Name:LYMAN
Middle Name:VAL
Last Name:ROLLINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L
Other - Middle Name:VAL
Other - Last Name:ROLLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:144 S 500 E
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:801-479-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159564-1205207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05386Medicaid
UT930085282OtherRAILROAD
UT$$$$$$$$$11001OtherBC/BS
UT930085282OtherRAILROAD
UT05386Medicaid
UT$$$$$$$$$12001OtherBC/BS
UT005567208Medicare ID - Type Unspecified5475 S 500 E, OGDEN