Provider Demographics
NPI:1952353716
Name:BORGHOLTHAUS, JAY LESLIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:LESLIE
Last Name:BORGHOLTHAUS
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 1:301 S 4TH AVE # C-2
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6462
Mailing Address - Country:US
Mailing Address - Phone:208-637-0841
Mailing Address - Fax:208-237-6922
Practice Address - Street 1:301 S 4TH AVE # C-2
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6462
Practice Address - Country:US
Practice Address - Phone:208-637-0841
Practice Address - Fax:208-237-6922
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000308200Medicaid
IDU55458Medicare UPIN
ID1593901Medicare ID - Type Unspecified