Provider Demographics
NPI:1093911133
Name:EYE CLINIC OF IDAHO FALLS,PA
Entity Type:Organization
Organization Name:EYE CLINIC OF IDAHO FALLS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-3937
Mailing Address - Street 1:PO BOX 2410
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2410
Mailing Address - Country:US
Mailing Address - Phone:208-529-3937
Mailing Address - Fax:208-524-4380
Practice Address - Street 1:530 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4751
Practice Address - Country:US
Practice Address - Phone:208-529-3937
Practice Address - Fax:208-524-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3793207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00240930Medicaid
ID1205974136OtherINDIVIDUAL NPI
ID003572200Medicaid
ID00240930Medicaid
ID003572200Medicaid
ID0526460001Medicare NSC
ID1205974136OtherINDIVIDUAL NPI