Healthcare Provider Details

I. General information

NPI: 1750489100
Provider Name (Legal Business Name): MARK LEE CAPENER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 E 17TH ST SUITE B-2
IDAHO FALLS ID
83404-8042
US

IV. Provider business mailing address

2065 E 17TH ST SUITE B-2
IDAHO FALLS ID
83404-8042
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7244
  • Fax: 208-524-1088
Mailing address:
  • Phone: 208-524-7244
  • Fax: 208-524-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number8394
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: