Healthcare Provider Details

I. General information

NPI: 1255412771
Provider Name (Legal Business Name): TODD W MUMFORD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 N 2000 W
FARR WEST UT
84404-9810
US

IV. Provider business mailing address

1741 N 2000 W
FARR WEST UT
84404-9810
US

V. Phone/Fax

Practice location:
  • Phone: 17-315-5558
  • Fax: 801-731-3143
Mailing address:
  • Phone: 801-731-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5641
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8141255-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: