MEDICARE: GREG MICHAEL WENOM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	277432-9934	UT

General Provider Information

NPI Number	:	1356420590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREG MICHAEL WENOM O.D.

Provider Business Mailing Address
First Line	:	1005 PINNOCCHIO DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-2132
Country	:	US
Telephone Number	:	801-355-6613
Fax Number	:

Provider Business Practice Location Address
First Line	:	5735 HARRISON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-4324
Country	:	US
Telephone Number	:	801-393-9440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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