Provider Demographics
NPI:1477656460
Name:DELL'AGLIO, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:DELL'AGLIO
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 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-6458
Mailing Address - Fax:208-343-5031
Practice Address - Street 1:2235 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8026
Practice Address - Country:US
Practice Address - Phone:208-887-3724
Practice Address - Fax:208-887-1682
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13433207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477656460Medicaid
MT000003781OtherBCSB PIN
WY100935400OtherMDCD PIN
ID1477656460Medicaid
MT000080903Medicare PIN
MT1153260003Medicare PIN
MTB42260Medicare UPIN
MT000082424Medicare PIN
MT000003781OtherBCSB PIN