Provider Demographics
NPI:1952781262
Name:KOWALLIS, CADE JOHN (OD)
Entity Type:Individual
Prefix:
First Name:CADE
Middle Name:JOHN
Last Name:KOWALLIS
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 1:165 W 200 N # 71-1
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2834
Mailing Address - Country:US
Mailing Address - Phone:435-823-2984
Mailing Address - Fax:
Practice Address - Street 1:165 W 200 N # 71-1
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2834
Practice Address - Country:US
Practice Address - Phone:435-823-2984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9420139-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist