Provider Demographics
NPI:1962592782
Name:KIMBALL, JORY T (OD)
Entity type:Individual
Prefix:DR
First Name:JORY
Middle Name:T
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8806 REDWOOD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5194
Mailing Address - Country:US
Mailing Address - Phone:801-578-2020
Mailing Address - Fax:801-748-4892
Practice Address - Street 1:8806 REDWOOD RD STE 101
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5194
Practice Address - Country:US
Practice Address - Phone:801-578-2020
Practice Address - Fax:801-748-4892
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5922926-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV05478Medicare UPIN