Provider Demographics
NPI:1821051400
Name:BROWN, DEAN I (OD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:I
Last Name:BROWN
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 1:380 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1559
Mailing Address - Country:US
Mailing Address - Phone:208-547-2020
Mailing Address - Fax:208-547-2114
Practice Address - Street 1:201 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5782
Practice Address - Country:US
Practice Address - Phone:208-547-7153
Practice Address - Fax:208-547-2060
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6016TG152W00000X
OR2902 AT152W00000X
WY399T152W00000X
ID100162152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV2741OtherBLUE CROSS OF IDAHO
ID000010170301OtherBLUE SHIELD
ID000010170302OtherBLUE SHIELD
ID80262400Medicaid
IDV2741OtherBLUE CROSS OF IDAHO
ID000010170302OtherBLUE SHIELD
ID80262401Medicaid