1568559029 NPI number — DR. ROBIN D SEBASTIAN M.D., FAAFP

Table of content: DR. ROBIN D SEBASTIAN M.D., FAAFP (NPI 1568559029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568559029 NPI number — DR. ROBIN D SEBASTIAN M.D., FAAFP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEBASTIAN
Provider First Name:
ROBIN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., FAAFP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568559029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 E LOCUST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMMETT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83617-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-6004
Provider Business Mailing Address Fax Number:
208-365-3589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 E LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-6004
Provider Business Practice Location Address Fax Number:
208-365-3589
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MT188205 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: M10681 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MD435743 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000010174773 . This is a "REGENCE BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: MD125789 . This is a "OREGON LICENSE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: M10681 . This is a "IDAHO LICENSE NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 808440301 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808440302 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 808440300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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