Provider Demographics
NPI:1639155617
Name:PICKETT, GREG M (OD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:M
Last Name:PICKETT
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 1:1196 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-0353
Mailing Address - Country:US
Mailing Address - Phone:801-399-9873
Mailing Address - Fax:801-399-2013
Practice Address - Street 1:1196 30TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-0353
Practice Address - Country:US
Practice Address - Phone:801-399-9873
Practice Address - Fax:801-399-2013
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3087349934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0372640001Medicare NSC
UT410029002Medicare PIN
UTU57725Medicare UPIN
UT000090532Medicare PIN