Basic Information
| Provider Information | |||||||||
| NPI: | 1982785770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | BRYAN | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015813195 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841321000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812352 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 109346-9934 | UT | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.