Provider Demographics
NPI:1225141120
Name:WIRTS, J. RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:RAY
Last Name:WIRTS
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 1:192 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2628
Mailing Address - Country:US
Mailing Address - Phone:801-261-2020
Mailing Address - Fax:801-261-2052
Practice Address - Street 1:192 E 4500 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-2628
Practice Address - Country:US
Practice Address - Phone:801-261-2020
Practice Address - Fax:801-261-2052
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109220-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT78118Medicare UPIN