Provider Demographics
NPI:1770577058
Name:PICKERING, ROGER M (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:M
Last Name:PICKERING
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 1:159 E MAIN ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2288
Mailing Address - Country:US
Mailing Address - Phone:801-766-1696
Mailing Address - Fax:801-766-1822
Practice Address - Street 1:159 E MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2288
Practice Address - Country:US
Practice Address - Phone:801-766-1696
Practice Address - Fax:801-766-1822
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2008-04-20
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
UT4776849-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
290672OtherALTIUS HEALTH PLANS
UT47768499900001OtherBLUE CROSS BLUE SHIELD
UT$$$$$$$$$001Medicaid
UTU81198Medicare UPIN