MEDICARE: EVAN MELVILLE DO

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	2080S0010X	Pediatric Sports Medicine Physician	O-1882	ID

General Provider Information

NPI Number	:	1942867148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN MELVILLE DO

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2619 W FAIRVIEW AVE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-6722
Country	:	US
Telephone Number	:	208-706-9311
Fax Number	:	208-489-4300

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

Provider Enumeration Date	:	05/22/2019
Last Update Date	:	12/05/2025

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Directions to “ EVAN MELVILLE DO” Practice Location

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