Healthcare Provider Details

I. General information

NPI: 1891780334
Provider Name (Legal Business Name): JOEL I BROWN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W NORTH ST
GRANGEVILLE ID
83530-1240
US

IV. Provider business mailing address

622 W NORTH ST
GRANGEVILLE ID
83530-1240
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-0260
  • Fax: 208-983-0047
Mailing address:
  • Phone: 208-983-0260
  • Fax: 208-983-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0-869
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: