Provider Demographics
NPI:1639240864
Name:DATTILO, GINGER L (MD)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:L
Last Name:DATTILO
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:PO BOX 828
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:ID
Mailing Address - Zip Code:83313-0828
Mailing Address - Country:US
Mailing Address - Phone:720-301-2055
Mailing Address - Fax:
Practice Address - Street 1:111 RIDGVIEW DR.
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:ID
Practice Address - Zip Code:83313-0828
Practice Address - Country:US
Practice Address - Phone:720-301-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20663207R00000X
CO43963207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR272459Medicaid
D93354Medicare UPIN
OR272459Medicaid