Provider Demographics
NPI:1356457030
Name:RHINEHART, BRADLEY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:LYNN
Last Name:RHINEHART
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 1:4055 EASTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4740
Mailing Address - Country:US
Mailing Address - Phone:208-542-2428
Mailing Address - Fax:
Practice Address - Street 1:700 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6152
Practice Address - Country:US
Practice Address - Phone:208-522-2839
Practice Address - Fax:208-522-0843
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807144200Medicaid
ID1594423Medicare ID - Type Unspecified
ID807144200Medicaid