Provider Demographics
NPI:1821109059
Name:RIGTRUP, CHAD L (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:L
Last Name:RIGTRUP
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 1:1675 N 200 W
Mailing Address - Street 2:#11A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2570
Mailing Address - Country:US
Mailing Address - Phone:801-374-2227
Mailing Address - Fax:
Practice Address - Street 1:1675 N 200 W
Practice Address - Street 2:#11A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2570
Practice Address - Country:US
Practice Address - Phone:801-374-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5950660-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid
UTV06150Medicare UPIN
UT$$$$$$$$$001Medicaid