1255449898 NPI number — HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY, PC

Table of content: ONIZAN EL ALEEM BEY MHS (NPI 1689064040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255449898 NPI number — HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY, PC
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:
1255449898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2375 E SUNNYSIDE RD STE J
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-8281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-525-4888
Provider Business Mailing Address Fax Number:
208-525-4885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE RD STE J
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:
83404-8281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-525-4888
Provider Business Practice Location Address Fax Number:
208-525-4885
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-525-4888

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X , with the licence number:  M7012 , 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)





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