Provider Demographics
NPI:1972565216
Name:COTTONWOOD EYE & LASER CLINIC, P.C.
Entity Type:Organization
Organization Name:COTTONWOOD EYE & LASER CLINIC, P.C.
Other - Org Name:STEVEN T JACKSON MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-268-6600
Mailing Address - Street 1:201 E 5900 S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7379
Mailing Address - Country:US
Mailing Address - Phone:801-268-6600
Mailing Address - Fax:801-268-6602
Practice Address - Street 1:201 E 5900 S
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7379
Practice Address - Country:US
Practice Address - Phone:801-268-6600
Practice Address - Fax:801-268-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1083659262Medicare PIN
UT1447215173Medicare PIN
UT1851362339Medicare PIN
UT1467411223Medicare PIN
UT1356310940Medicare PIN
UT1093822561Medicare PIN
UT1699774026Medicare PIN