Provider Demographics
NPI:1942202957
Name:HARDIN, CREIGHTON ALVES (MD)
Entity Type:Individual
Prefix:DR
First Name:CREIGHTON
Middle Name:ALVES
Last Name:HARDIN
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 1:1151 HOSPITAL WAY
Mailing Address - Street 2:BUILDING F
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5091
Mailing Address - Country:US
Mailing Address - Phone:208-232-1443
Mailing Address - Fax:208-239-3434
Practice Address - Street 1:1151 HOSPITAL WAY
Practice Address - Street 2:BUILDING F
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-232-1443
Practice Address - Fax:208-239-3434
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3986173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003746600Medicaid
ID003746600Medicaid