Healthcare Provider Details

I. General information

NPI: 1871598631
Provider Name (Legal Business Name): DOUGLAS U. BLANK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

IV. Provider business mailing address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-2985
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-3373
  • Fax: 208-523-8746
Mailing address:
  • Phone: 208-523-3373
  • Fax: 208-523-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM-7866
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: