Healthcare Provider Details

I. General information

NPI: 1184375867
Provider Name (Legal Business Name): IDAHO SKIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W CHUBBUCK RD
CHUBBUCK ID
83202-2314
US

IV. Provider business mailing address

147 W CHUBBUCK RD
CHUBBUCK ID
83202-2314
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-7546
  • Fax: 208-237-9643
Mailing address:
  • Phone: 208-238-7546
  • Fax: 208-237-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: EARL STODDARD
Title or Position: OWNER
Credential: MD
Phone: 208-238-7546