Provider Demographics
NPI:1033179288
Name:PORTH, KAREN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-2800
Mailing Address - Fax:208-367-7111
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-367-2800
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT84822084N0400X
IDM-126532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121828000Medicaid
000084697Medicare PIN
MTB58279Medicare UPIN
MT0147329Medicaid