Provider Demographics
NPI:1518051366
Name:HOLLOPETER, WAYNE L (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:HOLLOPETER
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 1:721 W. NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530
Mailing Address - Country:US
Mailing Address - Phone:208-983-0300
Mailing Address - Fax:208-983-9176
Practice Address - Street 1:721 W. NORTH STREET
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530
Practice Address - Country:US
Practice Address - Phone:208-983-0300
Practice Address - Fax:208-983-9176
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001613OtherREGENCE BLUESHIELD OF IDA
ID32169OtherBLUECROSS OF IDAHO
ID000010001613OtherREGENCE BLUESHIELD OF IDA
IDB63205Medicare UPIN