Provider Demographics
NPI:1154493708
Name:ASSOCIATED WESTSIDE OPTOMETRIC CLINIC P.A.
Entity Type:Organization
Organization Name:ASSOCIATED WESTSIDE OPTOMETRIC CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HILBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-4333
Mailing Address - Street 1:1991 W BROADWAY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1991 W BROADWAY ST STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3041
Practice Address - Country:US
Practice Address - Phone:208-529-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378915Medicare ID - Type Unspecified
IDT44361Medicare UPIN