Provider Demographics
NPI:1467525949
Name:HENDRICKSON, DAN J (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:J
Last Name:HENDRICKSON
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-2100
Mailing Address - Fax:208-302-2125
Practice Address - Street 1:401 E HAWAII
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-302-2100
Practice Address - Fax:208-302-2125
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9672207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010158154OtherREGENCE
ID807658900Medicaid
ID000010158154OtherREGENCE
IDE09241Medicare UPIN
P00430067Medicare PIN
ID1134935Medicare PIN