Provider Demographics
NPI:1639169626
Name:PITMAN, DEANNA M (DO)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:M
Last Name:PITMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:215 E HAWAII AVE # 140
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-514-2502
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1639169626Medicaid
ID000010150852OtherBLUE SHIELD
ID75085OtherBLUE CROSS
ID807228800Medicaid
ID807228900OtherHEALTHY CONNECTIONS
1131295Medicare PIN