Provider Demographics
NPI:1972609972
Name:HACKNEY, TODD (O D)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:HACKNEY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 S HIGHWAY 191
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-3629
Mailing Address - Country:US
Mailing Address - Phone:435-259-9441
Mailing Address - Fax:435-259-2431
Practice Address - Street 1:3031 S HIGHWAY 191
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-3629
Practice Address - Country:US
Practice Address - Phone:435-259-9441
Practice Address - Fax:435-259-2431
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT94-277458-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000090450Medicare ID - Type UnspecifiedUTAH MEDICARE
UT4200440001Medicare UPIN