Provider Demographics
NPI:1851466197
Name:WYBROW, MASON MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:MASON
Middle Name:MATTHEW
Last Name:WYBROW
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 1:308 N MARKET PLACE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1702
Mailing Address - Country:US
Mailing Address - Phone:801-294-6111
Mailing Address - Fax:801-294-6222
Practice Address - Street 1:308 N MARKET PLACE DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-1702
Practice Address - Country:US
Practice Address - Phone:801-294-6111
Practice Address - Fax:801-294-6222
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7730250-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist