Provider Demographics
NPI:1437159423
Name:VANCE, CARL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:DAVID
Last Name:VANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3910 WASHINGTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-523-1122
Mailing Address - Fax:208-523-2582
Practice Address - Street 1:3910 WASHINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7596
Practice Address - Country:US
Practice Address - Phone:208-523-1122
Practice Address - Fax:208-523-2582
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7763207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID25853OtherBLUESHIELD OF IDAHO
ID32035OtherDMBA
ID120165400OtherWYOMING CONSULTEC EDS
ID110187174OtherRAILROAD MEDICARE
ID805400000Medicaid
IDDZ643OtherBLUECROSS OF IDAHO
ID804012300OtherHEALTHY CONNECTIONS
ID804012300OtherHEALTHY CONNECTIONS
ID805400000Medicaid