Provider Demographics
NPI:1982639787
Name:HARRIE, ROGER PETTIT (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:PETTIT
Last Name:HARRIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:P
Other - Last Name:HARRIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:385-282-2000
Mailing Address - Fax:385-282-2001
Practice Address - Street 1:389 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2310
Practice Address - Country:US
Practice Address - Phone:385-282-2000
Practice Address - Fax:385-282-2001
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164819-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005545619Medicare PIN
D07333Medicare UPIN