Provider Demographics
NPI:1760433684
Name:HOMER, SCOTT W (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:HOMER
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 1:800 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6151
Mailing Address - Country:US
Mailing Address - Phone:208-522-0159
Mailing Address - Fax:208-522-3066
Practice Address - Street 1:800 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6151
Practice Address - Country:US
Practice Address - Phone:208-522-0159
Practice Address - Fax:208-522-3066
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP727152W00000X
WAOD00001953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT81733Medicare UPIN
ID1591748Medicare ID - Type Unspecified