Provider Demographics
NPI:1861408379
Name:PITKIN, D. H (OD)
Entity type:Individual
Prefix:
First Name:D.
Middle Name:H
Last Name:PITKIN
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 1:10169 W CRANBERRY CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-2116
Mailing Address - Country:US
Mailing Address - Phone:208-375-2369
Mailing Address - Fax:
Practice Address - Street 1:6700 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8727
Practice Address - Country:US
Practice Address - Phone:208-376-3550
Practice Address - Fax:208-321-2710
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0DP-510152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002455800Medicaid
ID002455800Medicaid
ID15917921Medicare PIN
ID0306910001Medicare NSC