Provider Demographics
NPI:1639289721
Name:GIAUQUE, CARL L (OD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:L
Last Name:GIAUQUE
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 1:139 N 4100 E
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5983
Mailing Address - Country:US
Mailing Address - Phone:208-745-0139
Mailing Address - Fax:
Practice Address - Street 1:1201 S 25TH E
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5729
Practice Address - Country:US
Practice Address - Phone:208-524-8978
Practice Address - Fax:208-524-8980
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 1062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1594164Medicare ID - Type Unspecified
IDT10076Medicare UPIN