Provider Demographics
NPI:1629067921
Name:HOOPES, PHILLIP CARL SR (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:CARL
Last Name:HOOPES
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 SOUTH STATE STREET
Mailing Address - Street 2:200
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7160
Mailing Address - Country:US
Mailing Address - Phone:801-568-0200
Mailing Address - Fax:
Practice Address - Street 1:11820 SO STATE ST.
Practice Address - Street 2:200
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7160
Practice Address - Country:US
Practice Address - Phone:801-568-0200
Practice Address - Fax:801-563-0200
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1616761205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT510929546001Medicaid
B74246Medicare UPIN
UT510929546001Medicaid