Provider Demographics
NPI:1518978337
Name:HOMAECHEVARRIA, ALEJANDRO A (MD)
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:A
Last Name:HOMAECHEVARRIA
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-383-0201
Mailing Address - Fax:208-489-4010
Practice Address - Street 1:1109 W MYRTLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6970
Practice Address - Country:US
Practice Address - Phone:208-383-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8320207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
20000903Medicare PIN