Provider Demographics
NPI:1710988894
Name:PERTTULA, ERIC W (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:W
Last Name:PERTTULA
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 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-528-8777
Mailing Address - Fax:208-528-9777
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-528-8777
Practice Address - Fax:208-528-9777
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806018000Medicaid
ID1100305Medicare ID - Type Unspecified
ID806018000Medicaid