Healthcare Provider Details

I. General information

NPI: 1659476844
Provider Name (Legal Business Name): MICHAEL L OGLESBAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8382 N WAYNE DR STE 205
HAYDEN ID
83835-6028
US

IV. Provider business mailing address

6848 N GOVERNMENT WAY STE 114 PMB 105
DALTON GARDENS ID
83815-7799
US

V. Phone/Fax

Practice location:
  • Phone: 208-665-8111
  • Fax:
Mailing address:
  • Phone: 208-773-1311
  • Fax: 208-773-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0631
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberO-0631
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: