Healthcare Provider Details

I. General information

NPI: 1285759753
Provider Name (Legal Business Name): BRENT ANTHONY GALVAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8102 W NORTHVIEW ST
BOISE ID
83704-4406
US

IV. Provider business mailing address

8102 W NORTHVIEW ST
BOISE ID
83704-4406
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-1102
  • Fax: 208-377-5853
Mailing address:
  • Phone: 208-377-1102
  • Fax: 208-377-5853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberODP100-177
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: