Organization
EAGLE DERMATOLOGY, PLLC
Active
Organization
EAGLE DERMATOLOGY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENNIFER ANNETTE GUERRERO (PRACTICE MANAGER)
(208) 391-7210
Entity
Organization
Contact information
Practice address
323 E RIVERSIDE DR STE 234, EAGLE, ID 83616-6865
(208) 391-7210
(208) 391-2130
Mailing address
372 S EAGLE RD # 126, EAGLE, ID 83616-5908
(208) 391-7210
(208) 391-2130
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
O-1094
ID
207ND0101X
MOHS-Micrographic Surgery Physician
O-1094
ID
207ND0900X
Dermatopathology Physician
O-1094
ID
207NI0002X
Clinical & Laboratory Dermatological Immunology Physician
O-1094
ID
207NP0225X
Pediatric Dermatology Physician
O-1094
ID
207NS0135X
Procedural Dermatology Physician
O-1094
ID
Other
Enumeration date
02/06/2018
Last updated
02/06/2018
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