Provider Demographics
NPI:1407984925
Name:DREW C DAYTON CHARTERED
Entity Type:Organization
Organization Name:DREW C DAYTON CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-585-9500
Mailing Address - Street 1:622 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5502
Mailing Address - Country:US
Mailing Address - Phone:208-585-9500
Mailing Address - Fax:208-585-9497
Practice Address - Street 1:622 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5502
Practice Address - Country:US
Practice Address - Phone:208-585-9500
Practice Address - Fax:208-585-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807484800Medicaid
IDU09949Medicare UPIN
ID807484800Medicaid
ID5796480001Medicare NSC