Provider Demographics
NPI:1437210994
Name:MARK E HINKSON DERMATOLOGY PA
Entity Type:Organization
Organization Name:MARK E HINKSON DERMATOLOGY PA
Other - Org Name:MOUNTAIN WEST DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:HINKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-528-6653
Mailing Address - Street 1:3425 MERLIN DR STE 200
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7430
Mailing Address - Country:US
Mailing Address - Phone:208-528-6653
Mailing Address - Fax:208-528-6676
Practice Address - Street 1:3425 MERLIN DR STE 200
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-528-6653
Practice Address - Fax:208-528-6676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-323207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID863436OtherDMBA
ID10147364OtherBLUE SHIELS
IDS4927OtherBLUE CROSS
ID1377099Medicare ID - Type UnspecifiedMEDICARE