Provider Demographics
NPI:1003951401
Name:ETO, STANLEY G (DPM)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:G
Last Name:ETO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4731
Mailing Address - Country:US
Mailing Address - Phone:208-459-0891
Mailing Address - Fax:208-459-8628
Practice Address - Street 1:112 W LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4731
Practice Address - Country:US
Practice Address - Phone:208-459-0891
Practice Address - Fax:208-459-8628
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-89213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44252Medicare UPIN
ID1376010Medicare ID - Type UnspecifiedMEDICARE PROVIDER #