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General NPI Number Information
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NPI Number | 1053493809
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Entity Type | Organization
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Legal Business Name | DJ MARC CARDINAL, MD PA
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 10/20/2011
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Provider Practice Location Address
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Address Line | 98 POPLAR ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-1758
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Country | US
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Telephone | 208-785-3810
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2896
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City | IDAHO FALLS
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State | ID
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Zip | 83403-2896
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Country | US
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Telephone | 208-523-4906
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Fax | 208-523-2025
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Authorized Official
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Title or Position | PRESIDENT
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Name | DJ MARC CARDINAL
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Credential | MD
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Telephone | 208-785-3810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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