Provider Demographics
NPI:1326239534
Name:PAUL BIGELOW OD PC
Entity Type:Organization
Organization Name:PAUL BIGELOW OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGELOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-342-4841
Mailing Address - Street 1:415 E PARKCENTER BLVD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6504
Mailing Address - Country:US
Mailing Address - Phone:208-342-4841
Mailing Address - Fax:
Practice Address - Street 1:415 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 127
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6504
Practice Address - Country:US
Practice Address - Phone:208-342-4841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDG1593OtherRAILROAD MEDICARE
ID5370710001Medicare NSC