Healthcare Provider Details

I. General information

NPI: 1134302433
Provider Name (Legal Business Name): EARL ANTHONY GAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO STREET, SUITE 303
BOISE ID
83712-6269
US

IV. Provider business mailing address

100 E IDAHO STREET, SUITE 303
BOISE ID
83712-6269
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-4772
  • Fax: 314-251-5772
Mailing address:
  • Phone: 208-433-1736
  • Fax: 208-433-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2012011130
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberM-17141
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: