Provider Demographics
NPI:1407549207
Name:GAGNON, JEREMIAH (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:GAGNON
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 1:710 W SUPERIOR ST STE B
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1684
Mailing Address - Country:US
Mailing Address - Phone:208-946-7187
Mailing Address - Fax:
Practice Address - Street 1:710 W SUPERIOR ST STE B
Practice Address - Street 2:
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:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODO-100614152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist