Provider Demographics
NPI:1942563424
Name:HUBER, LAUREN MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MARIE
Last Name:HUBER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:MARIE
Other - Last Name:CASAVANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2563 W TANGO CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5996
Mailing Address - Country:US
Mailing Address - Phone:207-233-3633
Mailing Address - Fax:
Practice Address - Street 1:27 N FISHER PARK WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4796
Practice Address - Country:US
Practice Address - Phone:208-514-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-1000250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20001413OtherMEDICARE PTAN