Unknown Individual – General Practice Physician, NPI 1033179049
General Practice Physician
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Unknown Individual
285 W 800 S
Roosevelt, UT 840663707
Phone: (435) 725-6300
Fax: (435) 725-6325
Type: Location
9, West 500 South, Vernal, Uintah County, Utah, 84078, United States
VERNAL, UT 840782912
Phone: (435) 789-6300
Fax: (435) 789-6325
Type: Mailing
1140, West 500 South, Vernal, Uintah County, Utah, 84078, United States
VERNAL, UT 840782914
Phone: (435) 789-6300
Fax: (435) 789-6325
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20120313000670 | I | General Practice | UT | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 84066)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Clinical Social Worker | UT | |
| Mental Health Counselor | UT | |
| Mental Health Counselor | UT | |
| O B S T E T R I C S/ G Y N E C O L O G Y | UT | |
| Marriage And Family Therapist | UT | |
| Clinical Social Worker | UT | |
| Marriage And Family Therapist | UT | |
| Clinical Social Worker | UT | |
| Clinical Social Worker | UT | |
| Clinical Social Worker | UT |
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