Provider Demographics
NPI:1417456385
Name:EAGLE DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:EAGLE DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-391-7210
Mailing Address - Street 1:372 S EAGLE RD # 126
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5908
Mailing Address - Country:US
Mailing Address - Phone:208-391-7210
Mailing Address - Fax:208-391-2130
Practice Address - Street 1:323 E RIVERSIDE DR STE 234
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6865
Practice Address - Country:US
Practice Address - Phone:208-391-7210
Practice Address - Fax:208-391-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1094207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty