Individual
SKY R BLUE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
125 E IDAHO ST, SUITE 203, BOISE, ID 83712-6212
(208) 338-0148
(208) 336-4027
Mailing address
125 E IDAHO ST, SUITE 203, BOISE, ID 83712-6212
(208) 338-0148
(208) 336-4027
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
07/08/2007
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