Provider Demographics
NPI:1033121538
Name:DEAN, JAMES K (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:K
Last Name:DEAN
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 1:343 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-467-0001
Mailing Address - Fax:208-466-2205
Practice Address - Street 1:343 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2856
Practice Address - Country:US
Practice Address - Phone:208-467-0001
Practice Address - Fax:208-466-2205
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44350Medicare UPIN
ID0255820001Medicare NSC
ID1591444Medicare PIN