Provider Demographics
NPI:1760903363
Name:DATTANI, SHEEV INDRAVADAN (MD)
Entity Type:Individual
Prefix:
First Name:SHEEV
Middle Name:INDRAVADAN
Last Name:DATTANI
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-2400
Mailing Address - Fax:208-302-2455
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-2400
Practice Address - Fax:208-302-2455
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13990208C00000X
FLME133177208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery