Healthcare Provider Details

I. General information

NPI: 1073756359
Provider Name (Legal Business Name): RYAN BRENT UDINK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD ST
BOISE ID
83704-8969
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5150
  • Fax: 208-302-5155
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7281913
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number010492
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO160999
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: