Provider Demographics
NPI:1598871899
Name:LEWISTON EYE CLINIC PA
Entity Type:Organization
Organization Name:LEWISTON EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:MEEHAN
Authorized Official - Last Name:BALDECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-2241
Mailing Address - Street 1:2214 VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-2241
Mailing Address - Fax:208-743-5871
Practice Address - Street 1:2214 VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-2241
Practice Address - Fax:208-743-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2629207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID26294OtherBLUE CROSS
WA1022144Medicaid
173777OtherCOMBINED INS CO OF AMER
548D7BAOtherBLUE LINKS
IDD205000OtherREGENCE
209714100000OtherPREMERA
209714100000OtherPREMERA
548D7BAOtherBLUE LINKS