Healthcare Provider Details

I. General information

NPI: 1083813844
Provider Name (Legal Business Name): BRANDON ROLLER M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 POLE LINE RD W
TWIN FALLS ID
83301-5799
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-1500
  • Fax:
Mailing address:
  • Phone: 208-381-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-17465
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number210518
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: