Provider Demographics
NPI:1639257017
Name:BEWLEY, JAMES RUSSELL (OD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RUSSELL
Last Name:BEWLEY
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 1:420 E ELM STREET
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4846
Mailing Address - Country:US
Mailing Address - Phone:208-459-2020
Mailing Address - Fax:208-459-2034
Practice Address - Street 1:420 E ELM STREET
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4846
Practice Address - Country:US
Practice Address - Phone:208-459-2020
Practice Address - Fax:208-459-2034
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807263100Medicaid
ID1100199Medicare PIN