Provider Demographics
NPI:1053314864
Name:SECREST, ALVIN JACKSON III (MD)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:JACKSON
Last Name:SECREST
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0565
Mailing Address - Country:US
Mailing Address - Phone:208-962-3267
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002284400Medicaid
ID1128089Medicare PIN
ID002284400Medicaid