Healthcare Provider Details

I. General information

NPI: 1639256670
Provider Name (Legal Business Name): MATTHEW DALE PARRY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 500 E SUITE #350
LOGAN UT
84341-2408
US

IV. Provider business mailing address

1300 N 500 E SUITE #350
LOGAN UT
84341-2408
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-7445
  • Fax: 435-753-3059
Mailing address:
  • Phone: 435-752-7445
  • Fax: 435-753-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6273691-9934
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: