Provider Demographics
NPI:1043222383
Name:CROFT, BRENT LARRY (OD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LARRY
Last Name:CROFT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1341 W 360 N
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4614
Mailing Address - Country:US
Mailing Address - Phone:435-688-9183
Mailing Address - Fax:435-673-9181
Practice Address - Street 1:301 E TABERNACLE ST
Practice Address - Street 2:STE. 101
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7108
Practice Address - Country:US
Practice Address - Phone:435-673-3558
Practice Address - Fax:435-673-9181
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT283951-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU75840Medicare UPIN
UT005737401Medicare PIN