MEDICARE: MR. SCOTT H KOWALLIS 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	111999-9934	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	000009840	OTHER	UT	MEDICARE LEGACY NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00437	OTHER		VA
2	107009195101	OTHER		IHC
3	123252	OTHER		MBA
4	870444057K02	OTHER		EDUCATOR'S MUTUAL
5	UT1999	OTHER		EYEMED
6	12466	OTHER		PEHP
8	87041538400001	OTHER	UT	BCBS
9	87041538400001	OTHER		NTCA
10	1015	OTHER	UT	OPTICARE
11	87041538400001	OTHER	UT	VALUCARE
12	870444057	OTHER		VSP

General Provider Information

NPI Number	:	1861487050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT H KOWALLIS O.D.

Provider Business Mailing Address
First Line	:	165 W 200 N
Second Line	:	71-7
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-2981
Fax Number	:	435-722-3732

Provider Business Practice Location Address
First Line	:	165 W 200 N
Second Line	:	71-7
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-2981
Fax Number	:	435-722-3732

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	06/18/2008

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Directions to “ MR. SCOTT H KOWALLIS O.D.” Practice Location

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