Healthcare Provider Details

I. General information

NPI: 1013534890
Provider Name (Legal Business Name): BRENT SEXAUER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 W BOISE AVE
BOISE ID
83706-3503
US

IV. Provider business mailing address

685 N 4TH E
MOUNTAIN HOME ID
83647-2134
US

V. Phone/Fax

Practice location:
  • Phone: 208-384-9194
  • Fax:
Mailing address:
  • Phone: 208-599-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number100508
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: