Healthcare Provider Details

I. General information

NPI: 1831387125
Provider Name (Legal Business Name): MICHAEL F. PINGREE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 S 4155 W STE 4
WEST VALLEY CITY UT
84120-2079
US

IV. Provider business mailing address

3465 S 4155 W STE 5
WEST VALLEY CITY UT
84120-2081
US

V. Phone/Fax

Practice location:
  • Phone: 801-966-0081
  • Fax: 801-966-0218
Mailing address:
  • Phone: 801-966-0081
  • Fax: 801-966-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number47809529934
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number51179711205
License Number StateUT

VIII. Authorized Official

Name: DR. MICHAEL F. PINGREE
Title or Position: PRESIDENT
Credential: M.D. PC
Phone: 801-966-0081