Provider Demographics
NPI:1770578759
Name:WAITE, BONNIE KIM (MD, CHARTERED)
Entity type:Individual
Prefix:
First Name:BONNIE KIM
Middle Name:
Last Name:WAITE
Suffix:
Gender:F
Credentials:MD, CHARTERED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-1702
Mailing Address - Fax:208-342-7042
Practice Address - Street 1:1216 GARRITY BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8368
Practice Address - Country:US
Practice Address - Phone:208-343-6458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7308207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1112349Medicare PIN
IDG90730Medicare UPIN