Provider Demographics
NPI:1922257823
Name:MICHAEL R FLANDRO OD PA
Entity Type:Organization
Organization Name:MICHAEL R FLANDRO OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:REESE
Authorized Official - Last Name:FLANDRO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-232-6675
Mailing Address - Street 1:360 S ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3307
Mailing Address - Country:US
Mailing Address - Phone:208-232-6675
Mailing Address - Fax:208-232-5800
Practice Address - Street 1:360 S ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3307
Practice Address - Country:US
Practice Address - Phone:208-232-6675
Practice Address - Fax:208-232-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-702261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015363OtherREGENCE BLUE SHIELD OF IDAHO
ID410039268OtherMEDICARE RAILROAD RETIREMENT BOARD
ID002622900Medicaid
IDV2811OtherBLUE CROSS OF IDAHO
IDT81734Medicare UPIN
ID410039268OtherMEDICARE RAILROAD RETIREMENT BOARD
ID1591811Medicare PIN