Provider Demographics
NPI:1720194632
Name:CROMWELL, PHILIP GILBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GILBERT
Last Name:CROMWELL
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 1:134 N STATE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1143
Mailing Address - Country:US
Mailing Address - Phone:208-852-3030
Mailing Address - Fax:208-852-3031
Practice Address - Street 1:134 N STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1143
Practice Address - Country:US
Practice Address - Phone:208-852-3030
Practice Address - Fax:208-852-3031
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP607152W00000X
UT1109189934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1720194632Medicaid
UT1720194632Medicaid
ID15910411Medicare PIN
IDT44321Medicare UPIN
ID1720194632Medicaid