Provider Demographics
NPI:1982693966
Name:DOWDLE, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DOWDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 POMERELLE AVE STE H
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2068
Mailing Address - Country:US
Mailing Address - Phone:208-677-6170
Mailing Address - Fax:208-878-4974
Practice Address - Street 1:1408 POMERELLE AVE STE H
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2068
Practice Address - Country:US
Practice Address - Phone:208-677-6170
Practice Address - Fax:208-878-4974
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5511174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDOO2647700Medicaid
IDE04235Medicare UPIN
1122183Medicare ID - Type Unspecified