Healthcare Provider Details

I. General information

NPI: 1720017247
Provider Name (Legal Business Name): DANIEL JUDE ALLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/26/2022
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 S MIDDLETON RD STE B
MIDDLETON ID
83644-5369
US

IV. Provider business mailing address

PO BOX 277976
ATLANTA GA
30384-7976
US

V. Phone/Fax

Practice location:
  • Phone: 208-585-6311
  • Fax: 208-585-6221
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberO-387
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0387
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: