Healthcare Provider Details

I. General information

NPI: 1558550913
Provider Name (Legal Business Name): ALAN BRANT GUMMOW O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N 300 W SUITE 302
KAYSVILLE UT
84037-1852
US

IV. Provider business mailing address

307 N 300 W SUITE 302
KAYSVILLE UT
84037-1852
US

V. Phone/Fax

Practice location:
  • Phone: 801-444-9977
  • Fax: 801-444-2610
Mailing address:
  • Phone: 801-444-9977
  • Fax: 801-444-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6675342-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: