Provider Demographics
NPI:1023645090
Name:BIRD, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BIRD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11649 S 4000 W STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-6048
Mailing Address - Country:US
Mailing Address - Phone:801-253-3080
Mailing Address - Fax:
Practice Address - Street 1:11649 S 4000 W STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-6048
Practice Address - Country:US
Practice Address - Phone:801-253-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13983608-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology