Provider Demographics
NPI:1982766747
Name:SQUIRE, JEFFREY C (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:SQUIRE
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 1:1425 W MAIN ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3283
Mailing Address - Country:US
Mailing Address - Phone:406-586-2173
Mailing Address - Fax:406-586-3603
Practice Address - Street 1:1425 W MAIN ST
Practice Address - Street 2:UNIT B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3283
Practice Address - Country:US
Practice Address - Phone:406-586-2173
Practice Address - Fax:406-586-3603
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV248152W00000X
MT657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000023861OtherBCBS
MT0483752Medicaid
1316121627OtherGROUP NPI
MS2466476OtherDEA
MTMS1239765OtherDEA NUMBER
MTMS1239765OtherDEA NUMBER
MT000085167Medicare PIN
MTU25388Medicare UPIN
1316121627OtherGROUP NPI
MT000025160Medicare PIN
MT000025160Medicare PIN