Provider Demographics
NPI:1790757110
Name:REESE, WILLIAM CARLAN (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CARLAN
Last Name:REESE
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 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:1455 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7748
Practice Address - Country:US
Practice Address - Phone:801-226-3044
Practice Address - Fax:801-802-7326
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348323-8904152WC0802X
UT348323-9934152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87017934014001OtherBLUE CROSS/BLUE SHIELD
UT999000797009Medicaid
UTU97665Medicare UPIN
UT005749801Medicare ID - Type Unspecified
UT000062683Medicare PIN
UT0618950018Medicare NSC
UT000062684Medicare PIN
UT0618950012Medicare NSC