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Organization
DEPARTMENT OF OPHTHALMOLOGY - PEDIATRIC DIVISION
Active
Organization
DEPARTMENT OF OPHTHALMOLOGY - PEDIATRIC DIVISION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANDALL J OLSON MD (DEPARTMENT CHAIR)
(801) 581-3195
Entity
Organization
Contact information
Practice address
100 MARIO CAPECCHI DR, # 3650, SALT LAKE CITY, UT 84112-8924
(801) 581-3195
Mailing address
65 MARIO CAPECCHI DR, SALT LAKE CITY, UT 84132-0001
(801) 581-3195
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
NULL
152W00000X
Optometrist
—
—
152WP0200X
Pediatric Optometrist
—
NULL
152WP0200X
Pediatric Optometrist
—
—
156FC0800X
Contact Lens Technician/Technologist
—
NULL
156FC0800X
Contact Lens Technician/Technologist
—
—
156FC0801X
Contact Lens Fitter
—
NULL
156FC0801X
Contact Lens Fitter
—
—
207W00000X
Ophthalmology Physician
Primary
—
NULL
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100503637
NEVADA MEDICAID
NV
01
—
122451400
WYOMING MEDICAID
WY
01
—
806964900
IDAHO MEDICAID
ID
Enumeration date
06/18/2006
Last updated
09/20/2011
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