Individual
DR. VIVEK KANTAYYA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
300 S 23RD ST, BOISE, ID 83702-9100
(208) 344-3512
(208) 344-4898
Mailing address
3063 S OLD HICKORY ST, BOISE, ID 83716-5812
(815) 871-3628
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036081072
IL
207Q00000X
Family Medicine Physician
Primary
M-12703
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036081072
—
IL
Enumeration date
11/23/2005
Last updated
06/09/2015
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