# DEPARTMENT OF OPHTHALMOLOGY - PEDIATRIC DIVISION

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1467497156
- **Authorized official:** RANDALL J OLSON MD (DEPARTMENT CHAIR)
- **Authorized official phone:** (801) 581-3195

## Contact information

- **Practice address:** 100 MARIO CAPECCHI DR, \# 3650, SALT LAKE CITY, UT 84112-8924
- **Practice address phone:** (801) 581-3195
- **Mailing address:** 65 MARIO CAPECCHI DR, SALT LAKE CITY, UT 84132-0001
- **Mailing address phone:** (801) 581-3195

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 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 | — | NULL | Yes |
| 207W00000X | Ophthalmology Physician | — | — | Yes |

## Other

- **Enumeration date:** 06/18/2006
- **Last updated:** 09/20/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 100503637 | NEVADA MEDICAID | NV |
| 01 | — | 122451400 | WYOMING MEDICAID | WY |
| 01 | — | 806964900 | IDAHO MEDICAID | ID |