Provider Demographics
NPI:1558356824
Name:GOICOECHEA, PHILIP DUANE (OD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:DUANE
Last Name:GOICOECHEA
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:PO BOX 4907
Mailing Address - Street 2:700 WEST KENT
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4907
Mailing Address - Country:US
Mailing Address - Phone:406-541-3937
Mailing Address - Fax:406-541-1810
Practice Address - Street 1:115 WEST 3RD
Practice Address - Street 2:STE 210
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-1150
Practice Address - Country:US
Practice Address - Phone:406-541-3937
Practice Address - Fax:406-541-1810
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0480964Medicaid
ID807232300OtherMEDICAID
MT0480964Medicaid
T89236Medicare UPIN