Provider Demographics
NPI:1780919829
Name:BONTRAGER, GORDON SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:SCOTT
Last Name:BONTRAGER
Suffix:
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 1:43 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1325
Mailing Address - Country:US
Mailing Address - Phone:208-648-4771
Mailing Address - Fax:208-744-0140
Practice Address - Street 1:43 N 1ST E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1325
Practice Address - Country:US
Practice Address - Phone:208-648-4771
Practice Address - Fax:208-744-0140
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1734207Q00000X
TN2119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01478459OtherRAIDROAD MEDICARE
TN15285357Medicaid
IDMRM-1734OtherIDAHO BOARD OF MEDICINE - RESIDENCY
VA1780919829Medicaid
IDPA-2119OtherIDAHO BOARD OF MEDICINE - PA
IDPA-821OtherIDAHO STATE BOARD OF MEDICINE