Provider Demographics
NPI:1588672026
Name:IDAHO FALLS INFECTIOUS DISEASES, PLLC
Entity Type:Organization
Organization Name:IDAHO FALLS INFECTIOUS DISEASES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BUITRAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-8400
Mailing Address - Street 1:3614 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7573
Mailing Address - Country:US
Mailing Address - Phone:208-535-8400
Mailing Address - Fax:208-535-8409
Practice Address - Street 1:3614 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-535-8400
Practice Address - Fax:208-535-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374588Medicare ID - Type Unspecified