Provider Demographics
NPI:1487760740
Name:LITTLE, TERRY M (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:M
Last Name:LITTLE
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 1:4750 N FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2715
Mailing Address - Country:US
Mailing Address - Phone:208-375-0500
Mailing Address - Fax:208-375-4310
Practice Address - Street 1:4750 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-375-0500
Practice Address - Fax:208-375-4310
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-53207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS5258OtherBLUE CROSS
IDJ3698OtherBLUE CROSS
ID000010000238OtherBLUE SHIELD
ID000010152070OtherBLUE SHIELD
ID004313500Medicaid
IDJ3698OtherBLUE CROSS
ID1300620Medicare ID - Type Unspecified