Provider Demographics
NPI:1861640658
Name:LYNCH, BERNADETTE N (OD)
Entity type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:N
Last Name:LYNCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 E 700 N STE A
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1818
Mailing Address - Country:US
Mailing Address - Phone:435-882-6452
Mailing Address - Fax:435-882-3170
Practice Address - Street 1:88 E 700 N STE A
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1818
Practice Address - Country:US
Practice Address - Phone:435-882-6452
Practice Address - Fax:435-882-3170
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14072152W00000X
UT7229395-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0618950002Medicare PIN
UT000066199Medicare PIN
UT000066702Medicare PIN