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General NPI Number Information
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NPI Number | 1720194632
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Entity Type | Individual
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Provider Name | PHILIP GILBERT CROMWELL O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 02/16/2012
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Provider Practice Location Address
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Address Line | 134 N STATE ST SUITE A
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City | PRESTON
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State | ID
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Zip | 83263-1143
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Country | US
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Telephone | 208-852-3030
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Fax | 208-852-3031
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Provider Business Mailing Address
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Address Line | 134 N STATE ST SUITE A
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City | PRESTON
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State | ID
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Zip | 83263-1143
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Country | US
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Telephone | 208-852-3030
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Fax | 208-852-3031
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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 | ODP607
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1109189934
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License Number State | UT
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