Provider Demographics
NPI:1326257064
Name:PAPENFUSS, MARK RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RYAN
Last Name:PAPENFUSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9649
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4649
Mailing Address - Country:US
Mailing Address - Phone:208-472-8100
Mailing Address - Fax:208-472-8172
Practice Address - Street 1:1055 N CURTIS ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-2161
Practice Address - Fax:208-367-2989
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-06162085R0202X
ORDO1541202085R0202X
IL1250497362085R0202X
IA40812085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1302962Medicare PIN
ORR160052Medicare PIN