Provider Demographics
NPI:1356349492
Name:BUITRAGO, MARTHA I (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:I
Last Name:BUITRAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7573
Mailing Address - Country:US
Mailing Address - Phone:208-535-8400
Mailing Address - Fax:208-535-8409
Practice Address - Street 1:3614 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-535-8400
Practice Address - Fax:208-535-8409
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8675207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806532100Medicaid
ID1109395Medicare PIN
IDG82068Medicare UPIN