Healthcare Provider Details

I. General information

NPI: 1215054291
Provider Name (Legal Business Name): DR. KEVIN MCELROY, OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E CARMEL DR
MERIDIAN ID
83646-3301
US

IV. Provider business mailing address

50 E CARMEL DR
MERIDIAN ID
83646-3301
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-5252
  • Fax: 208-884-4280
Mailing address:
  • Phone: 208-888-5252
  • Fax: 208-884-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberO-653
License Number StateID

VIII. Authorized Official

Name: DR. KEVIN W MCELROY
Title or Position: PRESIDENT
Credential: O.D. P.A.
Phone: 208-888-5252