=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417489485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAN MCENTIRE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2017
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6259 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-489-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6259 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-489-1914
-----------------------------------------------------
Fax | 208-375-5286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 0101278290
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------