Provider Demographics
NPI:1306874763
Name:BIDDULPH, GREGORY EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EDWIN
Last Name:BIDDULPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:EDWIN
Other - Last Name:BIDDULPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3300 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7592
Mailing Address - Country:US
Mailing Address - Phone:208-522-6662
Mailing Address - Fax:208-522-0880
Practice Address - Street 1:3300 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7592
Practice Address - Country:US
Practice Address - Phone:208-522-6662
Practice Address - Fax:208-522-0880
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6968207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000552OtherBS
OR286007Medicaid
WY113909600Medicaid
ID00001000552OtherMEDIVANTAGE BS
TN20036025OtherRAILROAD MEDICARE
VA613028OtherBX BS VA
NC7608951Medicaid
ID0027971Medicaid
KY185543500OtherUS DEPARTMENT OF LABOR
ID29868OtherBXI
CA8157532OtherOUT OF STATE MEDICAL
VA613028OtherBX BS VA
TN20036025OtherRAILROAD MEDICARE
NC7608951Medicaid