Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | ODP100141 | ID |
NPI | 1003015363 |
---|---|
Provider Name | Dr. Brandon Fish |
First Address | Twin Falls, ID 83301-3382 |
Second Address | Twin Falls, ID 83301-3382 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2007 |
Last Update Date | 22/04/2009 |