Provider Demographics
NPI:1922110188
Name:STACKLE, ERIC GERAND (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GERAND
Last Name:STACKLE
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 1:2429 NORTH COLE ROAD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5907
Mailing Address - Country:US
Mailing Address - Phone:208-377-4190
Mailing Address - Fax:208-358-9157
Practice Address - Street 1:2429 NORTH COLE ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5907
Practice Address - Country:US
Practice Address - Phone:208-377-4190
Practice Address - Fax:208-358-9157
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1110175Medicaid
ID1110175Medicaid