Healthcare Provider Details

I. General information

NPI: 1558859165
Provider Name (Legal Business Name): ANURAG GADDAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date: 12/05/2018
Reactivation Date: 12/10/2018

III. Provider practice location address

775 POLE LINE RD W STE 112
TWIN FALLS ID
83301-5819
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8200
  • Fax: 208-933-4921
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number01096395A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number3981209
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: