Provider Demographics
NPI:1821094152
Name:MCNEEL, BRIAN J (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:MCNEEL
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:13900 W WAINWRIGHT DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5028
Mailing Address - Country:US
Mailing Address - Phone:208-938-2010
Mailing Address - Fax:208-938-2011
Practice Address - Street 1:360 E MALLARD DR
Practice Address - Street 2:STE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3945
Practice Address - Country:US
Practice Address - Phone:208-336-8700
Practice Address - Fax:208-426-0902
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2014-05-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDODP933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0043208Medicaid
ID1593437Medicare ID - Type UnspecifiedMEDICARE
ID0043208Medicaid
410041119Medicare PIN