Provider Demographics
NPI:1578780805
Name:OCULOPLASTIC SURGERY, INC.
Entity Type:Organization
Organization Name:OCULOPLASTIC SURGERY, INC.
Other - Org Name:STILL CANYON EYELID & FACIAL PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J J
Authorized Official - Last Name:OBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-363-3356
Mailing Address - Street 1:5200 S HIGHLAND DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7003
Mailing Address - Country:US
Mailing Address - Phone:801-363-3356
Mailing Address - Fax:801-533-9613
Practice Address - Street 1:5200 S HIGHLAND DR STE 201
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7003
Practice Address - Country:US
Practice Address - Phone:801-363-3356
Practice Address - Fax:801-533-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207WX0200X
UT6121812-1205207W00000X
UT171979-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT479544679030Medicaid
UT464491680001Medicaid
UT485924851015Medicaid
UT8806278OtherCIGNA JD MCCANN
UT61218121200001OtherREGENCE MR VAGEFI
UT1057048OtherCCN JD MCCANN
UT169804OtherUHC RICHARD L. ANDERSON
UT439484OtherCCN RL ANDERSON
UT479544679030Medicaid
UT47954467903001OtherREGENCE- R.L. ANDERSON
UT3007900003OtherCIGNA RL ANDERSON
UT48592485106001OtherREGENCE JDM SANDY
UT48592485102001OtherREGENCE JD MCCANN
UT48592485102001OtherREGENCE JD MCCANN
UT479544679030Medicaid