Provider Demographics
NPI:1760542609
Name:MCENTIRE, MERLIN LEON (OD)
Entity Type:Individual
Prefix:
First Name:MERLIN
Middle Name:LEON
Last Name:MCENTIRE
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 1:1200 TOWNE CENTRE BLVD SPC 2104
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2985
Mailing Address - Country:US
Mailing Address - Phone:801-852-4405
Mailing Address - Fax:
Practice Address - Street 1:1200 TOWNE CENTRE BLVD SPC 2104
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2985
Practice Address - Country:US
Practice Address - Phone:801-852-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT366355-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist