Provider Demographics
NPI:1972745594
Name:STODDARD MEDICAL, INC
Entity type:Organization
Organization Name:STODDARD MEDICAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-238-7546
Mailing Address - Street 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-237-9643
Practice Address - Street 1:147 W CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2314
Practice Address - Country:US
Practice Address - Phone:208-238-7546
Practice Address - Fax:208-237-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9280207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11311121OtherMEDICARE PTAN