Organization
IDAHO FALLS DERMATOLOGY P A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CORNELIUS PAUL BROOKE (M.D.)
(208) 522-8945
Entity
Organization
Contact information
Practice address
2001 S WOODRUFF AVE, STE 12A, IDAHO FALLS, ID 83404-6374
(208) 522-8945
Mailing address
2001 S WOODRUFF AVE, STE 12A, IDAHO FALLS, ID 83404-6374
(208) 522-8945
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
5809M
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
77186
BLUE CROSS
ID
05
—
807962200
—
ID
Enumeration date
01/25/2007
Last updated
07/05/2016
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