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5680 W Gage St, Boise, ID 83706-1326 | |
(208) 377-3937 | |
(208) 377-9455 |
Full Name | |
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Type | Facility |
Speciality | Ophthalmology |
Location | 5680 W Gage St, Boise, Idaho |
Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
Identifier | Type | State | Issuer |
---|---|---|---|
1356542542 | NPI | - | NPPES |
000160500 | Medicaid | ID | |
807072200 | Medicaid | ID | |
807072300 | Medicaid | ID | |
0857720001 | Other | ID | DMERC GROUP NO |
806834700 | Medicaid | ID | |
001553800 | Medicaid | ID |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
152W00000X | Optometrist | ODP-100002 (Idaho) | Secondary |
152W00000X | Optometrist | ODP-100417 (Idaho) | Secondary |
207W00000X | Ophthalmology | O-0860 (Idaho) | Primary |
Provider Name | Gary R Pabalis |
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Provider Type | Practitioner - Optometry |
Provider Identifiers | NPI Number: 1396740262 PECOS PAC ID: 5890682033 Enrollment ID: I20040302000692 |
Provider Name | Jacob Adam Mong |
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Provider Type | Practitioner - Ophthalmology |
Provider Identifiers | NPI Number: 1346535481 PECOS PAC ID: 3072824762 Enrollment ID: I20150622002594 |
Mailing Address | Practice Location Address |
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5680 W Gage St, Boise, ID 83706-1326 Ph: (208) 377-3937 | 5680 W Gage St, Boise, ID 83706-1326 Ph: (208) 377-3937 |