MEDICARE: JAIME MICHELLE ETTERLING OD

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	12306522-9934	UT

General Provider Information

NPI Number	:	1467027201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME MICHELLE ETTERLING OD

Provider Business Mailing Address
First Line	:	6936 ELM CREEK CT
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45044-9225
Country	:	US
Telephone Number	:	513-910-2198
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 E BRICKYARD RD STE 23
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2557
Country	:	US
Telephone Number	:	801-530-6628
Fax Number	:

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

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	05/24/2021

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