Provider Demographics
NPI:1386875268
Name:GIOVANINI, FRED ELMER (LD)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:ELMER
Last Name:GIOVANINI
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 1ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3929
Mailing Address - Country:US
Mailing Address - Phone:208-525-6002
Mailing Address - Fax:208-232-2558
Practice Address - Street 1:505 1ST STREET, SUITE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-525-6002
Practice Address - Fax:208-232-2558
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD35122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010009728OtherBLUE SHIELD OF IDAHO
WA753354100000OtherPREMERA BLUE CROSS
IDGD203OtherBLUE CROSS OF IDAHO
PA1650686OtherUNITED CONCORDIA
KY0005553418OtherAETNA
ID0041OtherDELTA DENTAL OF IDAHO
ID002725400Medicaid