Provider Demographics
NPI:1629364054
Name:NORDGREN, RICK (MD)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:
Last Name:NORDGREN
Suffix:
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 1:1791 E 280 N
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2400
Mailing Address - Country:US
Mailing Address - Phone:435-656-2020
Mailing Address - Fax:435-634-2646
Practice Address - Street 1:1791 E 280 N
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2400
Practice Address - Country:US
Practice Address - Phone:435-656-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11363238-1205207W00000X, 207WX0107X
IN01075209B207W00000X
NV19279207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201285680Medicaid
UTU000104096OtherMEDICARE