Healthcare Provider Details

I. General information

NPI: 1780919829
Provider Name (Legal Business Name): GORDON SCOTT BONTRAGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 N 1ST E
PRESTON ID
83263-1325
US

IV. Provider business mailing address

43 N 1ST E
PRESTON ID
83263-1325
US

V. Phone/Fax

Practice location:
  • Phone: 208-648-4771
  • Fax: 208-744-0140
Mailing address:
  • Phone: 208-648-4771
  • Fax: 208-744-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRM-1734
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2119
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: