Provider Demographics
NPI:1396867214
Name:RETINA ASSOCIATES OF UTAH, P.C.
Entity Type:Organization
Organization Name:RETINA ASSOCIATES OF UTAH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-312-2010
Mailing Address - Street 1:5169 COTTONWOOD ST STE 630
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6771
Mailing Address - Country:US
Mailing Address - Phone:801-281-3030
Mailing Address - Fax:801-281-3033
Practice Address - Street 1:5169 COTTONWOOD ST STE 630
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6771
Practice Address - Country:US
Practice Address - Phone:801-281-3030
Practice Address - Fax:801-281-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207W00000X
207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS8665OtherRAILROAD MEDICARE
UT000055490Medicare PIN