Provider Demographics
NPI:1710115332
Name:PEBLEY, MITCHELL ELI (OD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ELI
Last Name:PEBLEY
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 1:1901 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2001
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:1438 E MAIN ST
Practice Address - Street 2:#4
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3814
Practice Address - Country:US
Practice Address - Phone:801-753-7999
Practice Address - Fax:801-753-7996
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7378183-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1023242435Medicaid
UT0618950011Medicare NSC
UT000068365Medicare PIN
UT000068366Medicare PIN
UT1023242435Medicaid
UT0618950018Medicare NSC
UT000068795Medicare PIN