Healthcare Provider Details

I. General information

NPI: 1841921863
Provider Name (Legal Business Name): BRIAN J MCKEON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 E LINCOLN RD
IDAHO FALLS ID
83401-2128
US

IV. Provider business mailing address

1480 E LINCOLN RD
IDAHO FALLS ID
83401-2128
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-8686
  • Fax: 208-525-8684
Mailing address:
  • Phone: 208-525-8686
  • Fax: 208-525-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number111111
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: