Provider Demographics
NPI:1215120696
Name:WREN, LEE BROCK (OD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:BROCK
Last Name:WREN
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 1:715 W JUDICIAL ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2036
Mailing Address - Country:US
Mailing Address - Phone:208-785-2210
Mailing Address - Fax:208-785-2216
Practice Address - Street 1:715 W JUDICIAL ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2036
Practice Address - Country:US
Practice Address - Phone:208-785-2210
Practice Address - Fax:208-785-2216
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT66612099934152W00000X
IDODP-100148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215120696Medicaid
UT66612099900001OtherBLUE CROSS/BLUE SHIELD
UT999000797009Medicaid
UT0000062923Medicare PIN
ID1215120696Medicaid
UT0618950011Medicare NSC
UT999000797009Medicaid