Provider Demographics
NPI:1366647729
Name:ENNIS, ROBERT F (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:ENNIS
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 1:1626 WELLS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4524
Mailing Address - Country:US
Mailing Address - Phone:208-994-8180
Mailing Address - Fax:
Practice Address - Street 1:1626 WELLS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4524
Practice Address - Country:US
Practice Address - Phone:208-994-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11309207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000826Medicare PIN