Provider Demographics
NPI:1750489100
Name:CAPENER, MARK LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEE
Last Name:CAPENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-524-7244
Mailing Address - Fax:208-524-1088
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE B-2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-524-7244
Practice Address - Fax:208-524-1088
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-05-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ID8394207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805970200Medicaid
IDF90674Medicare UPIN
ID805970200Medicaid