Provider Demographics
NPI:1225651011
Name:GILLETT, BETHANY RUTH (OD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:RUTH
Last Name:GILLETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:RUTH
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3029 S COLT PLAZA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-4015
Mailing Address - Country:US
Mailing Address - Phone:801-968-6772
Mailing Address - Fax:801-968-6771
Practice Address - Street 1:3029 S COLT PLAZA DR STE 1
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-4015
Practice Address - Country:US
Practice Address - Phone:801-968-6772
Practice Address - Fax:801-968-6771
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117805229934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1174708663OtherMOUNTAIN WEST EYECARE, LLC