Healthcare Provider Details

I. General information

NPI: 1871581652
Provider Name (Legal Business Name): BLAINE F BIRD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W SUITE 204
PROVO UT
84604-3344
US

IV. Provider business mailing address

1055 N 300 W SUITE 204
PROVO UT
84604-3344
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7373
  • Fax: 801-357-7217
Mailing address:
  • Phone: 801-357-7373
  • Fax: 801-357-7217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number114554-8908
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number114554-9934
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number114554-9934
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number114554-9934
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: