Provider Demographics
NPI:1740286723
Name:POGUE, BRYAN C SR (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:POGUE
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-463-3308
Practice Address - Street 1:9850 ST LUKES DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:208-288-4951
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1119170Medicare ID - Type Unspecified
IDC47901Medicare UPIN
ID003874300Medicaid