Provider Demographics
NPI:1730121740
Name:CHICOINE, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CHICOINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4857
Practice Address - Country:US
Practice Address - Phone:208-459-7415
Practice Address - Fax:208-453-3200
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8223207Q00000X
MT63004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806006100Medicaid
IDA50832Medicare UPIN
ID1145747Medicare ID - Type Unspecified