Provider Demographics
NPI:1609208610
Name:EDEN, CHRISTINE LEA (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LEA
Last Name:EDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-2800
Mailing Address - Fax:208-302-2825
Practice Address - Street 1:1075 N CURTIS RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-2800
Practice Address - Fax:208-302-2825
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-150682086S0129X
IL125.063695208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery