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General NPI Number Information
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NPI Number | 1215968045
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Entity Type | Individual
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Provider Name | MATTHEW J FACKRELL DO
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Gender | Male
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 10/22/2024
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Provider Practice Location Address
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Address Line | 1441 PARKWAY DR
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City | BLACKFOOT
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State | ID
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Zip | 83221-1667
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Country | US
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Telephone | 208-785-2600
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Fax | 208-785-8185
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Provider Business Mailing Address
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Address Line | 1441 PARKWAY DR
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City | BLACKFOOT
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State | ID
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Zip | 83221-1667
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Country | US
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Telephone | 208-785-2600
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Fax | 208-785-8185
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OP61556804
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO221842
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS024313
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DR.0073268
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License Number State | CO
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