Healthcare Provider Details

I. General information

NPI: 1760903363
Provider Name (Legal Business Name): SHEEV INDRAVADAN DATTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY STREET STE 201
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2400
  • Fax: 208-302-2455
Mailing address:
  • Phone: 208-302-2400
  • Fax: 208-302-2455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberM-13990
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME133177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: