MEDICARE: ISAIAH AUSTIN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	ODP100082	ID

General Provider Information

NPI Number	:	1760504237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISAIAH AUSTIN O.D.

Provider Business Mailing Address
First Line	:	217 BUCHANAN ST
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5242
Country	:	US
Telephone Number	:	208-948-5551
Fax Number	:	208-736-1596

Provider Business Practice Location Address
First Line	:	731 POLELINE RD
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3036
Country	:	US
Telephone Number	:	208-732-5688
Fax Number	:	208-736-1596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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