Healthcare Provider Details

I. General information

NPI: 1861408379
Provider Name (Legal Business Name): D. H. PITKIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 W EMERALD ST
BOISE ID
83704-8727
US

IV. Provider business mailing address

10169 W CRANBERRY CT
BOISE ID
83704-2116
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-3550
  • Fax: 208-321-2710
Mailing address:
  • Phone: 208-375-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0DP-510
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: