Healthcare Provider Details

I. General information

NPI: 1649275587
Provider Name (Legal Business Name): SCOTT ALLEN SHAPPARD SR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10255 W. OVERLAND RD
BOISE ID
83709-1430
US

IV. Provider business mailing address

3340 EAST GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5600
  • Fax: 208-302-5655
Mailing address:
  • Phone: 208-302-5600
  • Fax: 208-302-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO292
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-292
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: