Healthcare Provider Details

I. General information

NPI: 1760988364
Provider Name (Legal Business Name): SAMUEL SAUNDERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax:
Mailing address:
  • Phone: 208-233-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO1688
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: