Provider Demographics
NPI:1518035336
Name:DANIEL K HINCKLEY MD PA
Entity Type:Organization
Organization Name:DANIEL K HINCKLEY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:HINCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-1764
Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-1764
Mailing Address - Fax:208-522-1766
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:ST A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-1764
Practice Address - Fax:208-522-1766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002665500Medicaid
ID002665500Medicaid
ID1376100Medicare ID - Type UnspecifiedMEDICARE ID