1932552379 NPI number — CRAIG J DENNY MD PROF CORP

Table of content: (NPI 1932552379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932552379 NPI number — CRAIG J DENNY MD PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG J DENNY MD PROF CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1932552379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4612 E MAJESTIC VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMMON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83406-8180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-681-7659
Provider Business Mailing Address Fax Number:
208-497-0843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2065 E 17TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-520-6053
Provider Business Practice Location Address Fax Number:
208-497-0843
Provider Enumeration Date:
07/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DENNY
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
208-681-7659

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  M-9188 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720071319 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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