Healthcare Provider Details

I. General information

NPI: 1467419150
Provider Name (Legal Business Name): MATTHEW DAVID DETEMPLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BENNETT AVE
BURLEY ID
83318-2676
US

IV. Provider business mailing address

1309 BENNETT AVE
BURLEY ID
83318-2676
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-7796
  • Fax: 208-678-7799
Mailing address:
  • Phone: 208-678-7796
  • Fax: 208-678-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-339
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: