Provider Demographics
NPI:1659476844
Name:OGLESBAY, MICHAEL L (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:OGLESBAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E POLSTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6139
Mailing Address - Country:US
Mailing Address - Phone:208-773-1311
Mailing Address - Fax:208-773-1644
Practice Address - Street 1:1110 E POLSTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6139
Practice Address - Country:US
Practice Address - Phone:208-773-1311
Practice Address - Fax:208-773-1644
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDBO4467608OtherDEA
OR38-3856Medicare ID - Type UnspecifiedRURAL HEALTH
OR113902Medicaid
ORG34325Medicare UPIN
OR276278Medicaid