Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | ODP-100014 | ID |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | ODP-100014 | ID |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | ODP-100014 | ID |
N | 152WP0200X | Pediatric Optomitrist | ODP-100014 | ID |
N | 152WS0006X | Sports Vision | ODP-100014 | ID |
N | 152WV0400X | Optomitrist - Vision Therapist | ODP-100014 | ID |
N | 152WX0102X | Occupational Vision | ODP-100014 | ID |
NPI | 1144260969 |
---|---|
Provider Name | Dr. Bryce Byram Thueson |
First Address | Rexburg, ID 83440-2047 |
Second Address | Rexburg, ID 83440-2047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2006 |
Last Update Date | 22/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010146982 | BLUE SHIELD (01) | ID |
807155800 | (05) | ID |
ODP-100014 | IDAHO OPTOMETRY LICENSE (01) | ID |
U95270 | (02) | ID |
V631-7 | BLUE CROSS (01) | ID |