Provider Demographics
NPI:1194818997
Name:SCOVILLE, CRAIG D (MD)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:D
Last Name:SCOVILLE
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 1:2220 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7542
Mailing Address - Country:US
Mailing Address - Phone:208-542-9080
Mailing Address - Fax:208-542-9081
Practice Address - Street 1:2220 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7542
Practice Address - Country:US
Practice Address - Phone:208-542-9080
Practice Address - Fax:208-542-9081
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5232207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003958200Medicaid
1119462Medicare ID - Type Unspecified
B63913Medicare UPIN