Provider Demographics
NPI:1538284252
Name:SLAVIN, BRUCE (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:SLAVIN
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 1:818 MAIN ST
Mailing Address - Street 2:STE E
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4350
Mailing Address - Country:US
Mailing Address - Phone:208-756-3600
Mailing Address - Fax:208-756-3772
Practice Address - Street 1:818 MAIN ST
Practice Address - Street 2:STE E
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4350
Practice Address - Country:US
Practice Address - Phone:208-756-3600
Practice Address - Fax:208-756-3772
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-0836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015348OtherBLUE SHIELD IDAHO
IDV7268OtherBLUE CROSS IDAHO
ID0587110001OtherDMERC
ID000010015348OtherBLUE SHIELD IDAHO
ID1592214Medicare ID - Type Unspecified