Provider Demographics
NPI:1366607996
Name:RETINA SPECIALISTS OF IDAHO, PLLC
Entity type:Organization
Organization Name:RETINA SPECIALISTS OF IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-5624
Mailing Address - Street 1:13923 W WAINWRIGHT DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-398-5624
Mailing Address - Fax:208-938-5764
Practice Address - Street 1:13923 W WAINWRIGHT DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1969
Practice Address - Country:US
Practice Address - Phone:208-938-5624
Practice Address - Fax:208-938-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10066207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808025900Medicaid
ID808025900Medicaid
H90320Medicare UPIN