Healthcare Provider Details

I. General information

NPI: 1659365575
Provider Name (Legal Business Name): SKY R BLUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E IDAHO ST SUITE 203
BOISE ID
83712-6212
US

IV. Provider business mailing address

125 E IDAHO ST SUITE 203
BOISE ID
83712-6212
US

V. Phone/Fax

Practice location:
  • Phone: 208-338-0148
  • Fax: 208-336-4027
Mailing address:
  • Phone: 208-338-0148
  • Fax: 208-336-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberM7398
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: