Provider Demographics
NPI:1558310318
Name:DAINES, JOSEPH GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:GORDON
Last Name:DAINES
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 1:766 W COLCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5888
Mailing Address - Country:US
Mailing Address - Phone:208-401-4790
Mailing Address - Fax:
Practice Address - Street 1:766 W COLCHESTER DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5888
Practice Address - Country:US
Practice Address - Phone:208-401-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3286207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003653900Medicaid
IDP00185340OtherTRAVELERS MEDICARE
ID000010003325OtherREGENCE BLUE SHIELD
ID32862OtherBLUE CROSS
IDP00185340OtherTRAVELERS MEDICARE
ID1112628Medicare ID - Type Unspecified