Provider Demographics
NPI:1083931067
Name:UNDURRAGA PERL, VICENTE JOSE (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:JOSE
Last Name:UNDURRAGA PERL
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-2600
Mailing Address - Fax:208-302-2625
Practice Address - Street 1:999 N CURTIS ROAD
Practice Address - Street 2:STE 415
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-2600
Practice Address - Fax:208-302-2625
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14232208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery