Provider Demographics
NPI:1467419150
Name:DETEMPLE, MATTHEW DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:DETEMPLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2676
Mailing Address - Country:US
Mailing Address - Phone:208-678-7796
Mailing Address - Fax:208-678-7799
Practice Address - Street 1:1308 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2665
Practice Address - Country:US
Practice Address - Phone:208-678-7796
Practice Address - Fax:208-678-7799
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1128178Medicare Oscar/Certification
IDH81212Medicare UPIN