Provider Demographics
NPI:1134302433
Name:GAGE, EARL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:ANTHONY
Last Name:GAGE
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 1:100 E IDAHO STREET, SUITE 303
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6269
Mailing Address - Country:US
Mailing Address - Phone:208-433-1736
Mailing Address - Fax:208-433-1738
Practice Address - Street 1:100 E IDAHO STREET, SUITE 303
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6269
Practice Address - Country:US
Practice Address - Phone:314-251-4772
Practice Address - Fax:314-251-5772
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011130208200000X
IDM-17141208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134302433Medicaid