Healthcare Provider Details

I. General information

NPI: 1508152257
Provider Name (Legal Business Name): TOBIAS P GOPON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N ROBBINS RD STE 400
BOISE ID
83702-4566
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-2663
  • Fax: 208-489-4300
Mailing address:
  • Phone: 208-706-8526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM-11854
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: