Provider Demographics
NPI:1417155086
Name:FILLMORE, PARKER R (MD)
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:R
Last Name:FILLMORE
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-7676
Mailing Address - Fax:208-367-5595
Practice Address - Street 1:999 N CURTIS ROAD
Practice Address - Street 2:STE 415
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-1334
Practice Address - Country:US
Practice Address - Phone:208-367-7676
Practice Address - Fax:208-367-5595
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-132352086S0127X, 208600000X
AZ44866208600000X
MDD00754962086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ASO2532199372OtherDEA
MDD0075496OtherLICENSE
NVLL1759OtherNV MEDICAL LICENSE
NVASO2532199372OtherNV BOARD OF PHARM
AZ44866OtherLICENSE