Healthcare Provider Details

I. General information

NPI: 1477501930
Provider Name (Legal Business Name): CDS,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY BLDG A, STE 300
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

777 HOSPITAL WAY BLDG A, STE 300
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-6100
  • Fax: 208-239-3403
Mailing address:
  • Phone: 208-239-3453
  • Fax: 208-239-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateID

VIII. Authorized Official

Name: DR. DONALD A DYER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-232-3252