Provider Demographics
NPI:1699774026
Name:JUDKINS, MICHAEL MERLIN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MERLIN
Last Name:JUDKINS
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 1:5331 ADAMS AVE PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4753
Mailing Address - Country:US
Mailing Address - Phone:801-479-7850
Mailing Address - Fax:
Practice Address - Street 1:5331 ADAMS AVE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4753
Practice Address - Country:US
Practice Address - Phone:801-479-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375535-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU76411Medicare UPIN
UT000067128Medicare PIN
UTP00752818Medicare PIN