Healthcare Provider Details

I. General information

NPI: 1487383238
Provider Name (Legal Business Name): TODD MICHAEL DUNAWAY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 NW 16TH ST STE 101
FRUITLAND ID
83619-2265
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-8100
  • Fax: 208-452-8111
Mailing address:
  • Phone: 866-626-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2481401
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11022165A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025-01574
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: