Provider Demographics
NPI:1356630420
Name:TALBOT, BRETT SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:SCOTT
Last Name:TALBOT
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 1:2265 E SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7598
Mailing Address - Country:US
Mailing Address - Phone:208-542-5000
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM136542085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13566304720Medicaid