Provider Demographics
NPI:1629163639
Name:WHITESIDES, PAUL D (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:WHITESIDES
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 1:999 N CURTIS RD
Mailing Address - Street 2:# 205
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-9999
Mailing Address - Country:US
Mailing Address - Phone:208-373-1200
Mailing Address - Fax:208-373-1216
Practice Address - Street 1:999 N CURTIS RD
Practice Address - Street 2:# 205
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-9999
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:208-373-1216
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP473152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV4734OtherBLUE CROSS OF IDAHO
ID000010015330OtherREGENCE BLUE SHIELD OF ID
IDT44317Medicare UPIN
ID000010015330OtherREGENCE BLUE SHIELD OF ID