Provider Demographics
NPI:1780671347
Name:HALL, D ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:D
Middle Name:ERIC
Last Name:HALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-887-6813
Mailing Address - Fax:208-887-6884
Practice Address - Street 1:3090 E GENTRY WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3501
Practice Address - Country:US
Practice Address - Phone:208-887-6813
Practice Address - Fax:208-887-6884
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000423Medicare PIN