Healthcare Provider Details

I. General information

NPI: 1043217599
Provider Name (Legal Business Name): DANIEL JACK MEULENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N 3RD AVE STE 101
SANDPOINT ID
83864-1594
US

IV. Provider business mailing address

606 N 3RD AVE STE 101
SANDPOINT ID
83864-1594
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1435
  • Fax: 208-263-7812
Mailing address:
  • Phone: 208-263-5527
  • Fax: 208-263-4580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM5882
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: