Provider Demographics
NPI:1336273085
Name:DENAGY, STEPHEN A (M4915)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:DENAGY
Suffix:
Gender:M
Credentials:M4915
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6601
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:208-346-7501
Practice Address - Street 1:2705 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6601
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4915207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648500Medicaid
IDC36950OtherUPIN
ID000010005201OtherBLUE SHIELD OF IDAHO
ID820428306OtherCIGNA BEHAVIORAL HEALTH
ID1370128OtherMEDICARE GROUP
ID49155OtherBLUE CROSS OF IDAHO
IDG526301OtherTRICARE
ID49155OtherBLUE CROSS OF IDAHO