Provider Demographics
NPI:1609886514
Name:CRADDOCK, DUANE ELDON (MD)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:ELDON
Last Name:CRADDOCK
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 1:700 W IRONWOOD DR
Mailing Address - Street 2:STE 155
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-667-0585
Mailing Address - Fax:208-667-0876
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:STE 155
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-0585
Practice Address - Fax:208-667-0876
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7929208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDJ3995OtherBLUE CROSS OF IDAHO
ID000010028256OtherREGENCE BLUE SHIELD
ID000010028257OtherREGENCE BLUE SHIELD
MT1609886514Medicaid
WA8267114Medicaid
ID805750600Medicaid
IDJ3953OtherBLUE CROSS OF IDAHO
IDJ3995OtherBLUE CROSS OF IDAHO
1144200Medicare ID - Type Unspecified