Healthcare Provider Details

I. General information

NPI: 1205035961
Provider Name (Legal Business Name): LUCIANO COSTA AMADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 W JEFFERSON ST
BOISE ID
83702-6045
US

IV. Provider business mailing address

190 E BANNOCK ST STE W200
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-1680
  • Fax:
Mailing address:
  • Phone: 208-381-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberM-17240
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number107201
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number107201
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: