Provider Demographics
NPI:1801902333
Name:CROMWELL, JEFFREY L (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:CROMWELL
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 1:190 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1143
Mailing Address - Country:US
Mailing Address - Phone:435-563-5248
Mailing Address - Fax:
Practice Address - Street 1:1300 N 200 E
Practice Address - Street 2:SUITE 104
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2398
Practice Address - Country:US
Practice Address - Phone:435-752-6453
Practice Address - Fax:435-752-6486
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62492069934152W00000X
IDODP100129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055942OtherMEDICARE PTAN
ID1801902333Medicaid
ID1594509OtherMEDICARE PTAN
UT1801902333Medicaid