Provider Demographics
NPI:1184823049
Name:WARNER, TRENTON G (OD)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:G
Last Name:WARNER
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 1:1108 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3535
Mailing Address - Country:US
Mailing Address - Phone:208-365-2020
Mailing Address - Fax:208-365-3854
Practice Address - Street 1:1108 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3535
Practice Address - Country:US
Practice Address - Phone:208-365-2020
Practice Address - Fax:208-365-3854
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100-152152W00000X
IL46009990152W00000X
AZ1774152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184823049Medicaid