Provider Demographics
NPI:1437138203
Name:PAUL V HAKES OD INC
Entity Type:Organization
Organization Name:PAUL V HAKES OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAKES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-634-2232
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-1027
Mailing Address - Country:US
Mailing Address - Phone:208-634-2232
Mailing Address - Fax:208-634-1746
Practice Address - Street 1:204 LENORA ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:208-634-2232
Practice Address - Fax:208-634-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID04761969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010015318OtherREGENCE BLUE SHIELD
V0278OtherBLUE CROSS
ID002804100Medicaid
1594182Medicare ID - Type Unspecified
ID002804100Medicaid
000010015318OtherREGENCE BLUE SHIELD