Healthcare Provider Details

I. General information

NPI: 1720291024
Provider Name (Legal Business Name): AVINASH SHIVAPUTRAPPA PATIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4424 E FLAMINGO AVE STE 220
NAMPA ID
83687-9289
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-1100
  • Fax: 208-302-1155
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMC-2207
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number01073021A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number51869
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: