Provider Demographics
NPI:1376721324
Name:GAGNON, JULIE BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:BETH
Last Name:GAGNON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:BETH
Other - Last Name:GOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 W SUPERIOR ST
Mailing Address - Street 2:STE A
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1684
Mailing Address - Country:US
Mailing Address - Phone:208-263-9000
Mailing Address - Fax:208-263-9589
Practice Address - Street 1:710 W SUPERIOR ST
Practice Address - Street 2:STE A
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1684
Practice Address - Country:US
Practice Address - Phone:208-263-9000
Practice Address - Fax:208-263-9589
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U44332Medicare UPIN