Healthcare Provider Details

I. General information

NPI: 1134176548
Provider Name (Legal Business Name): TED D EPPERLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

2180 RIBIER DR
MERIDIAN ID
83642-5130
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6042
  • Fax: 208-947-1761
Mailing address:
  • Phone: 208-846-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-8362
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: