Provider Demographics
NPI:1164503959
Name:SCHUBACH, COLLEEN M (OD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SCHUBACH
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 1:1743 REDSTONE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7929
Mailing Address - Country:US
Mailing Address - Phone:435-658-9250
Mailing Address - Fax:
Practice Address - Street 1:1743 REDSTONE CENTER DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7929
Practice Address - Country:US
Practice Address - Phone:435-658-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111371-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist