Provider Demographics
NPI:1871581652
Name:BIRD, BLAINE F (OD)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:F
Last Name:BIRD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1055 N 300 W
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7373
Mailing Address - Fax:801-357-7217
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7373
Practice Address - Fax:801-357-7217
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114554-8908152WC0802X
UT114554-9934152WP0200X, 152WS0006X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU32943Medicare UPIN
UTU000078521Medicare PIN