=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598495384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKSON RILEY FITZGERALD OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2022
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 E 4TH AVE
-----------------------------------------------------
City | AFTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83110-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-885-3975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 S HILLSIDE DR
-----------------------------------------------------
City | ELK RIDGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84651-8501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-669-3687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 548T
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-OPT-LIC-4481
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------