Provider Demographics
NPI:1295753465
Name:ACKERSON, JOHN HAWES (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HAWES
Last Name:ACKERSON
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 1:736 W 100 S
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3739
Mailing Address - Country:US
Mailing Address - Phone:435-657-1212
Mailing Address - Fax:435-657-9522
Practice Address - Street 1:736 W 100 S
Practice Address - Street 2:SUITE #2
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3739
Practice Address - Country:US
Practice Address - Phone:435-657-1212
Practice Address - Fax:435-657-9522
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4764729-9934152W00000X
UT4764729-8904152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5280Medicaid
UT87-0668017OtherTAX ID NUMBER
UTU82846Medicare UPIN