Healthcare Provider Details

I. General information

NPI: 1831371467
Provider Name (Legal Business Name): DENNIS RADFORD OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E 17TH ST
IDAHO FALLS ID
83404-6152
US

IV. Provider business mailing address

PO BOX 3469
IDAHO FALLS ID
83403-3469
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-2839
  • Fax: 208-522-0848
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100115
License Number StateID

VIII. Authorized Official

Name: DR. DENNIS S RADFORD
Title or Position: OPTOMETRIST
Credential: O D
Phone: 208-525-2090