Provider Demographics
NPI:1891780334
Name:BROWN, JOEL I (OD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
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 1:622 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1240
Mailing Address - Country:US
Mailing Address - Phone:208-983-0260
Mailing Address - Fax:208-983-0047
Practice Address - Street 1:622 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1240
Practice Address - Country:US
Practice Address - Phone:208-983-0260
Practice Address - Fax:208-983-0047
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-869152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0620530001OtherMEDICARE DME
ID000010015436OtherREGENCE
ID0620530001Medicare NSC
IDU41396Medicare UPIN
ID0620530001OtherMEDICARE DME