Provider Demographics
NPI:1790960961
Name:IDAHO DIABETES AND ENDOCRINE ASSOCIATES, PA
Entity Type:Organization
Organization Name:IDAHO DIABETES AND ENDOCRINE ASSOCIATES, PA
Other - Org Name:IDAHO DIABETES & ENDOCRINE ASSOCIATES, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROOSEVELT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD, JD
Authorized Official - Phone:208-389-2213
Mailing Address - Street 1:13909 W. WAINWRIGHT DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-389-2213
Mailing Address - Fax:208-389-4659
Practice Address - Street 1:13909 W. WAINWRIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1969
Practice Address - Country:US
Practice Address - Phone:208-389-2213
Practice Address - Fax:208-389-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010035381OtherREGENCE BLUE SHIELD OF ID
ID002712100Medicaid
ID77021OtherBLUE CROSS OF IDAHO
IDA45381Medicare PIN