Provider Demographics
NPI:1659347144
Name:FROMM, KEVIN JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:FROMM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5455 W 11000 N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8800
Mailing Address - Country:US
Mailing Address - Phone:801-756-9357
Mailing Address - Fax:801-756-9358
Practice Address - Street 1:5455 W 11000 N
Practice Address - Street 2:SUITE 101
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8800
Practice Address - Country:US
Practice Address - Phone:801-756-9357
Practice Address - Fax:801-756-9358
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375345-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU77603Medicare UPIN