=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326239534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL BIGELOW OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 11/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 E PARKCENTER BLVD SUITE 127
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-342-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 E PARKCENTER BLVD SUITE 127
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-6504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-342-4841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PAUL BIGELOW
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 208-342-4841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-577
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------