Healthcare Provider Details

I. General information

NPI: 1942867148
Provider Name (Legal Business Name): EVAN MELVILLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W FAIRVIEW AVE
BOISE ID
83702-6722
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-9311
  • Fax: 208-489-4300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberO-1882
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: