MEDICARE: GINGER L. DATTILO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD20663	OR
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	43963	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639240864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINGER L. DATTILO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 828
Second Line	:
City	:	BELLEVUE
State	:	ID
Zip	:	83313-0828
Country	:	US
Telephone Number	:	720-301-2055
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 RIDGVIEW DR.
Second Line	:
City	:	BELLEVUE
State	:	ID
Zip	:	83313-0828
Country	:	US
Telephone Number	:	720-301-2055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	05/15/2015

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