Provider Demographics
NPI:1598954638
Name:ROWE, JUSTIN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MARK
Last Name:ROWE
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 1:204 LENORA ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3844
Mailing Address - Country:US
Mailing Address - Phone:208-634-4161
Mailing Address - Fax:208-634-1716
Practice Address - Street 1:339 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:208-634-2020
Practice Address - Fax:208-634-1716
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001924152W00000X
IDODP-100139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1598954638Medicaid
ID20004724Medicare PIN