Provider Demographics
NPI:1134342264
Name:DEER POINT FAMILY PRACTICE PC
Entity type:Organization
Organization Name:DEER POINT FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-322-7284
Mailing Address - Street 1:PO BOX 4979
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4979
Mailing Address - Country:US
Mailing Address - Phone:208-322-7284
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:6023 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-322-7284
Practice Address - Fax:208-323-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002643400Medicaid
ID000010028455OtherREGENCE BLUE SHIELD OF ID
ID000010028455OtherREGENCE BLUE SHIELD OF ID
ID1378016Medicare PIN