Healthcare Provider Details

I. General information

NPI: 1841787611
Provider Name (Legal Business Name): FORREST YEAKLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 AVIATION WAY
CALDWELL ID
83605-1154
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-7100
  • Fax: 208-302-7155
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036156716
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10439T
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberO-2015
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: