Provider Demographics
NPI:1487688990
Name:CHRISTENSEN, BRENT (DPM)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 E CLARK ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3357
Mailing Address - Country:US
Mailing Address - Phone:208-235-1777
Mailing Address - Fax:208-232-7518
Practice Address - Street 1:1777 E CLARK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-235-1777
Practice Address - Fax:208-232-7518
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-166213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152768OtherBLUE SHEILD
ID806402300Medicaid
IDP-1985OtherBLUE CROSS
ID71-0943024OtherFEIN
IDP00031188OtherMEDICARE RAIL ROAD
ID71-0943024OtherFEIN
IDU91821Medicare UPIN
ID1351091Medicare ID - Type Unspecified