Provider Demographics
NPI:1821106089
Name:HINCKLEY, DANIEL K (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:K
Last Name:HINCKLEY
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 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-1764
Mailing Address - Fax:208-522-1766
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-1764
Practice Address - Fax:208-522-1766
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002665500Medicaid
ID1376100Medicare ID - Type Unspecified
IDE69399Medicare UPIN