Provider Demographics
NPI:1336554674
Name:PHAIL, PAUL (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PHAIL
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 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1399
Mailing Address - Fax:208-985-1399
Practice Address - Street 1:4971 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2822
Practice Address - Country:US
Practice Address - Phone:208-378-4288
Practice Address - Fax:208-378-4297
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
IDO-1051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program