NPIMap

Organization Active NPI

Madison Clinic Optometry, P.C.

  • Optometrist
  • Rexburg, ID
National Provider Identifier
1598876997
Registry record updated Nov 28, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
MADISON CLINIC OPTOMETRY, P.C.
Practice address
244 E Main St
Rexburg, ID 83440-2022
Phone
(208) 359-1880
Fax
(208) 359-2025
NPI assigned
Aug 31, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 28, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Dallin Heiner, O.D.NPI 1245346980
Title
President
Phone
(208) 359-1880

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

244 E Main St
Rexburg, ID 83440-2022

Mailing address

244 E Main St
Rexburg, ID 83440-2022
Phone (208) 359-1880

Other identifiers 2

IdentifierTypeStateIssuer
V6499OtherIDBLUE CROSS
000010149064OtherIDREGENCE BLUE SHIELD OF ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040922000042 ID Part B Supplier - Clinic/Group Practice 8426026030 Receives reassigned benefits from 2 practitioners
Practice locations: Rexburg, ID

National Provider Directory

National Provider Directory

Locations

244 E Main St
Rexburg, ID 83440
Phone (208) 359-1880

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1196208000000",
    "number": "1598876997",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "244 E MAIN ST",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834402022",
            "telephone_number": "208-359-1880",
            "fax_number": "208-359-2025"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "244 E MAIN ST",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834402022",
            "telephone_number": "208-359-1880",
            "fax_number": "208-359-2025"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MADISON CLINIC OPTOMETRY, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-31",
        "last_updated": "2007-11-28",
        "status": "A",
        "authorized_official_last_name": "HEINER",
        "authorized_official_first_name": "DALLIN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-359-1880",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "V6499",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD OF ID",
            "identifier": "000010149064",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Rexburg, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 28, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.