Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2557 | AK |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 2557 | AK |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 2557 | AK |
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | O-81 | ID |
NPI | 1174598684 |
---|---|
Provider Name | Dr. Victor Bartling |
First Address | Meridian, ID 83642 |
Second Address | Boise, ID 83704 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/02/2006 |
Last Update Date | 27/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1011781 | (05) | AK |
BB1110472 | DEA NUMBER (01) | |
D33623 | (02) | AK |