Provider Demographics
NPI:1336175298
Name:DYGERT, LINCOLN (OD)
Entity Type:Individual
Prefix:DR
First Name:LINCOLN
Middle Name:
Last Name:DYGERT
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 1:3475 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1230
Mailing Address - Country:US
Mailing Address - Phone:801-394-8885
Mailing Address - Fax:801-394-8991
Practice Address - Street 1:3475 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1230
Practice Address - Country:US
Practice Address - Phone:801-394-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3624569934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU71691Medicare UPIN
UT005547302Medicare ID - Type Unspecified