Provider Demographics
NPI:1811091309
Name:MCGOURTY, BRIAN J (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:MCGOURTY
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 1:310 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-1361
Mailing Address - Fax:208-467-9008
Practice Address - Street 1:310 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-1361
Practice Address - Fax:208-467-9008
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002622300Medicaid
ID000010015424OtherREGENCE BLUE SHIELD
IDE00820496865OtherAETNA
ID82049686583651A001OtherTRICARE
IDV9063OtherBLUE CROSS
IDE00820496865OtherAETNA