Basic Information
| Provider Information | |||||||||
| NPI: | 1679583470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 W SOUTH JORDAN PKWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840959060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019529500 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 W SOUTH JORDAN PKWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840959060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012533080 | ||||||||
| FaxNumber: | 8012530772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 172302-1205 | UT | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | D0565 | 01 | UT | MEDICAID LICENSE NUMBER | OTHER | DH0042 | 01 | UT | RRMD GROUP | OTHER | 180043150 | 01 | UT | RAILROAD MEDICARE | OTHER | 1679583470 | 05 | UT | MEDICAID |