Provider Demographics
NPI:1801831151
Name:MCINTOSH, DANIEL BRODIE (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRODIE
Last Name:MCINTOSH
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 1:307 SAINT JOHNS WAY
Mailing Address - Street 2:STE #9
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2435
Mailing Address - Country:US
Mailing Address - Phone:208-746-7055
Mailing Address - Fax:208-746-4899
Practice Address - Street 1:307 SAINT JOHNS WAY
Practice Address - Street 2:STE #9
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2435
Practice Address - Country:US
Practice Address - Phone:208-746-7055
Practice Address - Fax:208-746-4899
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005765OtherREGENCE
ID54064OtherBLUE CROSS OF IDAHO
ID000826400Medicaid
ID1120800Medicare ID - Type Unspecified
ID54064OtherBLUE CROSS OF IDAHO