Provider Demographics
NPI:1346395746
Name:DRAGOTOIU, DAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:I
Last Name:DRAGOTOIU
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 1:1995 E 17TH ST
Mailing Address - Street 2:2
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-529-1076
Mailing Address - Fax:208-528-3332
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-523-6020
Practice Address - Fax:208-528-3332
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000594500Medicaid
ID1114117Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IDD73481Medicare UPIN