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General NPI Number Information
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NPI Number | 1558657783
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Entity Type | Individual
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Provider Name | RYAN DOUGLAS HUBER O.D.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2011
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 27 N FISHER PARK WAY STE 101
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City | EAGLE
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State | ID
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Zip | 83616-4795
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Country | US
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Telephone | 208-514-1858
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Fax | 844-840-3190
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Provider Business Mailing Address
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Address Line | 27 N FISHER PARK WAY STE 101
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City | EAGLE
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State | ID
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Zip | 83616-4795
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Country | US
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Telephone | 208-514-1858
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Fax | 208-576-6951
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-100228
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License Number State | ID
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