Provider Demographics
NPI:1568555001
Name:MCMAHON, DOUGLAS B (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:B
Last Name:MCMAHON
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 1:190 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:
Mailing Address - Fax:
Practice Address - Street 1:12080 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2462
Practice Address - Country:US
Practice Address - Phone:208-375-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO19768207Q00000X
IDM-17583207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR079587Medicaid
OR4002804-02OtherREGENCE PC 65
OR0237420-02OtherREGENCE BLUE CROSS OF OR
ORH2549-02OtherPACIFIC SOURCE
OR122912OtherDEPT OF LABOR WORK COMP
OR079587Medicaid
OR105754Medicare ID - Type Unspecified
ORH2549-02OtherPACIFIC SOURCE
OR4002804-02OtherREGENCE PC 65