Provider Demographics
NPI:1134176548
Name:EPPERLY, TED D (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:D
Last Name:EPPERLY
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 1:2180 RIBIER DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5130
Mailing Address - Country:US
Mailing Address - Phone:208-846-8222
Mailing Address - Fax:
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-367-6042
Practice Address - Fax:208-947-1761
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806253300Medicaid
ID11039791Medicare PIN
ID11039792Medicare PIN
IDF34188Medicare UPIN
ID1103979Medicare PIN