Provider Demographics
NPI:1063437630
Name:FONKEN, STEVEN J (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:FONKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7934207R00000X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010027675OtherREGENCE BLUE SHIELD OF ID
ID805658400Medicaid
59923OtherBLUE CROSS OF IDAHO
E32374Medicare UPIN
59923OtherBLUE CROSS OF IDAHO