Provider Demographics
NPI:1508286790
Name:MADISON, MICHAEL D (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MADISON
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 1:500 W FORT ST
Mailing Address - Street 2:#111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1314
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:#111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-26
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ID1508286790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program