Provider Demographics
NPI:1215071246
Name:ANTONIE, DAVID JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:ANTONIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 N DEVLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7313
Mailing Address - Country:US
Mailing Address - Phone:208-863-5409
Mailing Address - Fax:
Practice Address - Street 1:460 N MILWAUKEE ST
Practice Address - Street 2:SEARS OPTICAL
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9122
Practice Address - Country:US
Practice Address - Phone:208-375-3030
Practice Address - Fax:208-375-3030
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 896152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T-61373Medicare UPIN