Provider Demographics
NPI:1386939734
Name:SIMPSON, ISAC PHIL (DO)
Entity type:Individual
Prefix:DR
First Name:ISAC
Middle Name:PHIL
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 E 17TH ST STE 190
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6749
Mailing Address - Country:US
Mailing Address - Phone:208-524-2222
Mailing Address - Fax:855-999-9242
Practice Address - Street 1:3456 E 17TH ST STE 190
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6749
Practice Address - Country:US
Practice Address - Phone:208-524-2222
Practice Address - Fax:855-999-9242
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0854207Q00000X
TXQ0564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID473675862Medicaid
TX341964001Medicaid