Provider Demographics
NPI:1225195548
Name:DUTSON, THOMAS PAUL REDD (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL REDD
Last Name:DUTSON
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 1:10011 CENTENNIAL PKWY
Mailing Address - Street 2:400
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4156
Mailing Address - Country:US
Mailing Address - Phone:801-288-2020
Mailing Address - Fax:801-350-0288
Practice Address - Street 1:4400 S 700 E
Practice Address - Street 2:SUITE140
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3000
Practice Address - Country:US
Practice Address - Phone:801-288-2020
Practice Address - Fax:801-350-0288
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5148352-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT787584OtherDESERET MUTUAL BENEFITS
UT51483529900001OtherBCBS
UT70085OtherPEHP
UT000055763Medicare PIN
UT70085OtherPEHP
UT410049717Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT787584OtherDESERET MUTUAL BENEFITS
UTU93549Medicare UPIN