Provider Demographics
NPI:1295002285
Name:TAUB, ETHAN ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ALEXANDER
Last Name:TAUB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:999 N CURTIS RD STE 415
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1334
Practice Address - Country:US
Practice Address - Phone:208-302-2600
Practice Address - Fax:208-302-2625
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5741207P00000X, 208600000X
IL036137282208600000X
ID4061377208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320190706Medicaid
TX291187YKQHMedicare PIN