Provider Demographics
NPI:1972547172
Name:GOH, KENTON B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:B
Last Name:GOH
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 1:6640 KANIKSU ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-3141
Mailing Address - Fax:208-267-2202
Practice Address - Street 1:6640 KANIKSU ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-3141
Practice Address - Fax:208-267-2202
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11866207P00000X
TN24216207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF66228Medicare UPIN
TN3078075Medicaid
TNF66228Medicare UPIN