Provider Demographics
NPI:1508827262
Name:DUCLOS, LANNY F (OD)
Entity Type:Individual
Prefix:DR
First Name:LANNY
Middle Name:F
Last Name:DUCLOS
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 1:88 E 700 N
Mailing Address - Street 2:STE A
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1817
Mailing Address - Country:US
Mailing Address - Phone:435-882-6452
Mailing Address - Fax:435-882-3170
Practice Address - Street 1:88 E 700 N
Practice Address - Street 2:STE A
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1817
Practice Address - Country:US
Practice Address - Phone:435-882-6452
Practice Address - Fax:435-882-3170
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1138799934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1804229OtherWORKERS COMPENSATION
UT39123OtherPEHP
UTTPRA06734Medicaid
UT10898Medicaid
UTPR07206Medicaid
UTQM0000016583OtherALTIUS
UTD1110Medicaid
UTPR07206Medicaid
UTTPRA06734Medicaid