Provider Demographics
NPI:1437132479
Name:KANTAYYA, VIVEK (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVEK
Middle Name:
Last Name:KANTAYYA
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 1:3063 S OLD HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5812
Mailing Address - Country:US
Mailing Address - Phone:815-871-3628
Mailing Address - Fax:
Practice Address - Street 1:300 S 23RD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-9100
Practice Address - Country:US
Practice Address - Phone:208-344-3512
Practice Address - Fax:208-344-4898
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081072207Q00000X
IDM-12703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081072Medicaid
ILE46721Medicare UPIN
ID20006392Medicare UPIN