Provider Demographics
NPI:1245340314
Name:NAVE, JERRY BLAIR (OD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:BLAIR
Last Name:NAVE
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 1:2550 S 25TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-552-7323
Mailing Address - Fax:208-552-7325
Practice Address - Street 1:2550 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-552-7323
Practice Address - Fax:208-552-7325
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0818152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1307550001OtherNORIDIAN
ID004321400Medicaid
T92341Medicare UPIN
ID004321400Medicaid