Healthcare Provider Details

I. General information

NPI: 1821657222
Provider Name (Legal Business Name): REESE MARK LOVELESS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 N STATE ST
PROVO UT
84604-1010
US

IV. Provider business mailing address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1818
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number11330444-9934
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11330444-9934
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: