Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 5354412-9934 | UT |
NPI | 1013015650 |
---|---|
Provider Name | Dr. Michael D Conklin |
First Address | Sandy, UT 84093-1687 |
Second Address | Salt Lake City, UT 84115-5116 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |