Provider Demographics
NPI:1740385723
Name:FLANDRO, MICHAEL R (OD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:FLANDRO
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 1:360 SOUTH ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204
Mailing Address - Country:US
Mailing Address - Phone:208-232-6675
Mailing Address - Fax:208-232-5800
Practice Address - Street 1:360 SOUTH ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204
Practice Address - Country:US
Practice Address - Phone:208-232-6675
Practice Address - Fax:208-232-5800
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002622900Medicaid
ID0969700001OtherDMERC
000010015363OtherREGENCE BLUE SHIELD OF ID
ID410039268OtherRAILROAD MEDICARE
V2811OtherBLUE CROSS OF IDAHO
ID002622900Medicaid
000010015363OtherREGENCE BLUE SHIELD OF ID