Individual
BRENT CHRISTENSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
1777 E CLARK ST, SUITE 220, POCATELLO, ID 83201-3357
(208) 235-1777
(208) 232-7518
Mailing address
1777 E CLARK ST, SUITE 220, POCATELLO, ID 83201-3357
(208) 235-1777
(208) 232-7518
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
P-166
ID
213ES0103X
Foot & Ankle Surgery Podiatrist
P-166
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010152768
BLUE SHEILD
ID
01
—
71-0943024
FEIN
ID
05
—
806402300
—
ID
01
—
P-1985
BLUE CROSS
ID
01
—
P00031188
MEDICARE RAIL ROAD
ID
Enumeration date
07/10/2006
Last updated
06/20/2013
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