Provider Demographics
NPI:1306096979
Name:FARRELL, SCOTT D (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:FARRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 TALON CT
Mailing Address - Street 2:
Mailing Address - City:N SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2631
Mailing Address - Country:US
Mailing Address - Phone:801-448-4620
Mailing Address - Fax:801-298-4620
Practice Address - Street 1:640 TALON CT
Practice Address - Street 2:
Practice Address - City:N SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2631
Practice Address - Country:US
Practice Address - Phone:801-448-4620
Practice Address - Fax:801-298-4620
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109860-9933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1306096979Medicaid
UTPRA03404OtherMOLINA
UTPRA03404OtherMOLINA
UT1306096979Medicaid