=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770109282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN JONES OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2020
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 E 17TH ST SPC 157
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-3355
-----------------------------------------------------
Fax | 208-552-6120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3187
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83403-3187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-351-9190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-002440
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-100565
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------