# IDAHO DIABETES AND ENDOCRINE ASSOCIATES, PA

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Idaho Diabetes & Endocrine Associates, PA
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790960961
- **Authorized official:** DR. THEODORE S ROOSEVELT MD, PHD, JD (PRESIDENT)
- **Authorized official phone:** (208) 389-2213

## Contact information

- **Practice address:** 13909 W. WAINWRIGHT DRIVE, BOISE, ID 83713-1969
- **Practice address phone:** (208) 389-2213
- **Practice address fax:** (208) 389-4659
- **Mailing address:** 13909 W. WAINWRIGHT DRIVE, BOISE, ID 83713-1969
- **Mailing address phone:** (208) 389-2213
- **Mailing address fax:** (208) 389-4659

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | — | NULL | — |
| 174400000X | Specialist | — | — | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | NULL | Yes |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | — | — | Yes |

## Other

- **Enumeration date:** 01/07/2008
- **Last updated:** 05/18/2022