Provider Demographics
NPI:1508899295
Name:BOETTCHER, GREG C (DO)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:C
Last Name:BOETTCHER
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 1:267 N CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5500
Mailing Address - Country:US
Mailing Address - Phone:208-934-4446
Mailing Address - Fax:208-934-4442
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-4446
Practice Address - Fax:208-934-4442
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S4117OtherBLUE CROSS
ID000010141448OtherBLUE SHIELD
ID805804000Medicaid
ID1302057Medicare PIN
ID805804000Medicaid