Healthcare Provider Details

I. General information

NPI: 1750791471
Provider Name (Legal Business Name): ERIK DAVID SIBBERNSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 E STATE ST STE 2120
EAGLE ID
83616-6232
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-473-3275
  • Fax: 208-473-3276
Mailing address:
  • Phone: 208-813-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-17816
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number01075639A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPG168052
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: