Provider Demographics
NPI:1295823029
Name:PURDY, RUSSELL (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:PURDY
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 1:1901 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2001
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:1076 LAYTON HILLS MALL STE 2090
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2104
Practice Address - Country:US
Practice Address - Phone:801-546-0255
Practice Address - Fax:801-546-0260
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113333-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000797009Medicaid
UT241764OtherDMBA
UT$$$$$$$$$04001OtherBLUE CROSS/BLUE SHIELD
UT999000797009Medicaid
UT0618950009Medicare NSC
UT0618950010Medicare NSC
UT009430016Medicare PIN
UT0618950003Medicare NSC
000060096Medicare PIN
UT$$$$$$$$$03001OtherBLUE CROSS/BLUE SHIELD
UT004473017Medicare PIN
UTP00312688Medicare PIN