Provider Demographics
NPI:1750342655
Name:POWELL, SHANE K (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:K
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 300 N 75-3
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-3971
Mailing Address - Fax:435-722-6104
Practice Address - Street 1:210 W 300 N 75-3
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-3971
Practice Address - Fax:435-722-6104
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3083961205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3889Medicaid
UT006486029Medicare PIN
UTD3889Medicaid
UT1068670001Medicare NSC