Provider Demographics
NPI:1356420590
Name:WENOM, GREG MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:MICHAEL
Last Name:WENOM
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 1:1005 PINNOCCHIO DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2132
Mailing Address - Country:US
Mailing Address - Phone:801-355-6613
Mailing Address - Fax:
Practice Address - Street 1:5735 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4324
Practice Address - Country:US
Practice Address - Phone:801-393-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT277432-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU51149Medicare UPIN