1083663868 NPI number — DR. TIMOTHY EUGENE DOERR M.D.

Table of content: DR. TIMOTHY EUGENE DOERR M.D. (NPI 1083663868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083663868 NPI number — DR. TIMOTHY EUGENE DOERR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOERR
Provider First Name:
TIMOTHY
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1083663868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8854 W EMERALD ST
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704-4845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-321-4790
Provider Business Mailing Address Fax Number:
208-321-4836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8854 W EMERALD ST
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-321-4790
Provider Business Practice Location Address Fax Number:
208-321-4836
Provider Enumeration Date:
05/09/2006

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: 207X00000X , with the licence number:  M7259 , 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: P00171922 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010004063 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 804191700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 72595 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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