Provider Demographics
NPI:1346230356
Name:DJERNES, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:DJERNES
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 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3244
Mailing Address - Fax:208-463-3388
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-463-3197
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM57562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID39594OtherBLUE CROSS
ID002363800Medicaid
ID000010034804OtherBLUE SHIELD
ID000010001980OtherBLUE SHIELD
ID130007001OtherRAILROAD MEDICARE
ID57562OtherBLUE CROSS
ID45153OtherBLUE CROSS
ID39594OtherBLUE CROSS
ID20002297Medicare PIN
1124687Medicare PIN