Provider Demographics
NPI:1013928118
Name:OKELBERRY, KERRY ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:ALLEN
Last Name:OKELBERRY
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 1:6705 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-2402
Mailing Address - Country:US
Mailing Address - Phone:801-268-0866
Mailing Address - Fax:801-268-2092
Practice Address - Street 1:6705 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-2402
Practice Address - Country:US
Practice Address - Phone:801-268-0866
Practice Address - Fax:801-268-2092
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112-513-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDR 3610OtherRETIRED RAILROAD MEDICARE
UT41008204OtherRAILROAD MEDICARE
UT$$$$$$$$$008Medicaid
UTT78186Medicare UPIN
UT000065426Medicare PIN