Healthcare Provider Details

I. General information

NPI: 1477487346
Provider Name (Legal Business Name): AMMON JOEL VATERLAUS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4191 POLELINE RD STE C
POCATELLO ID
83202-2402
US

IV. Provider business mailing address

4191 POLELINE RD STE C
POCATELLO ID
83202-2402
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-7927
  • Fax:
Mailing address:
  • Phone: 208-239-7927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6581915
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: