Provider Demographics
NPI:1881764678
Name:BIRCH, JARED EDGAR (OD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:EDGAR
Last Name:BIRCH
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 1:1689 PANCHERI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3041
Mailing Address - Country:US
Mailing Address - Phone:208-529-4333
Mailing Address - Fax:208-529-4366
Practice Address - Street 1:1689 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3041
Practice Address - Country:US
Practice Address - Phone:208-529-4333
Practice Address - Fax:208-529-4366
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807002500Medicaid
IDV00703Medicare UPIN
ID1594297Medicare PIN