Basic Information
| Provider Information | |||||||||
| NPI: | 1104472349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND PEDIATRIC OPHTHALMOLOGY AND STRABISMUS P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 E SELTICE WAY | ||||||||
| Address2: | STE A PMB#277 | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83854 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2175 N MAIN ST | ||||||||
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| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838145768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086649888 | ||||||||
| FaxNumber: | 2086660816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLIZZARD | ||||||||
| AuthorizedOfficialFirstName: | SONYA | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2082743937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0110X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.