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Individual
SKY R BLUE
Active
Individual
SKY R BLUE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
Primary
M7398
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010000484
REGENCE BLUE SHIELD OF ID
ID
01
—
J1676
BLUE CROSS OF IDAHO
ID
Enumeration date
09/07/2005
Last updated
07/13/2026
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