1568555001 NPI number — DR. DOUGLAS B MCMAHON DO

Table of content: DR. DOUGLAS B MCMAHON DO (NPI 1568555001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568555001 NPI number — DR. DOUGLAS B MCMAHON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMAHON
Provider First Name:
DOUGLAS
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1568555001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12080 W MCMILLAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83713-2462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-375-4955
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2006

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:  DO19768 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: M-17583 , 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: 079587 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4002804-02 . This is a "REGENCE PC 65" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 0237420-02 . This is a "REGENCE BLUE CROSS OF OR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: H2549-02 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 122912 . This is a "DEPT OF LABOR WORK COMP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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