Provider Demographics
NPI:1962666438
Name:KOCARNIK, BEVERLY MIELKE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:MIELKE
Last Name:KOCARNIK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:ANN
Other - Last Name:MIELKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W FORT ST
Mailing Address - Street 2:CRH 2ND FLOOR
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1018
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:CRH 2ND FLOOR
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60234086207R00000X
WAMD 60234086207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8945072Medicare PIN