Provider Demographics
NPI:1639256670
Name:PARRY, MATTHEW DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DALE
Last Name:PARRY
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 1:1300 N 500 E
Mailing Address - Street 2:SUITE #350
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2408
Mailing Address - Country:US
Mailing Address - Phone:435-752-7445
Mailing Address - Fax:435-753-3059
Practice Address - Street 1:1300 N 500 E
Practice Address - Street 2:SUITE #350
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2408
Practice Address - Country:US
Practice Address - Phone:435-752-7445
Practice Address - Fax:435-753-3059
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6273691-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid
UTV12089Medicare UPIN
UT000060389Medicare PIN