Provider Demographics
NPI:1710980354
Name:ROCKY MOUNTAIN RETINA CONSULTANTS
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN RETINA CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GOODART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-264-4444
Mailing Address - Street 1:4400 S 700 E
Mailing Address - Street 2:STE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3000
Mailing Address - Country:US
Mailing Address - Phone:801-264-4444
Mailing Address - Fax:801-281-2383
Practice Address - Street 1:4400 S 700 E
Practice Address - Street 2:STE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3000
Practice Address - Country:US
Practice Address - Phone:801-264-4444
Practice Address - Fax:801-281-2383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055994Medicare PIN
MT180029059Medicare PIN
UTCS0812Medicare PIN
UT180029059Medicare PIN
WYW307585Medicare PIN
WYCS0812Medicare PIN
MT756181665Medicare PIN
UT756181665Medicare PIN
WY756181665Medicare PIN
MTCS0812Medicare PIN
MT000082852Medicare PIN
UT000055992Medicare PIN