Provider Demographics
NPI:1760400238
Name:STODDARD, EARL (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:STODDARD
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 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-237-9643
Practice Address - Street 1:147 W CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2314
Practice Address - Country:US
Practice Address - Phone:208-238-7546
Practice Address - Fax:208-237-9643
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9280207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807206400Medicaid
IDP00239843OtherRAILRAOD MEDICARE PTAN
ID807206400Medicaid