Provider Demographics
NPI:1801891569
Name:FEALKO, MONIKA GERDA (MD)
Entity type:Individual
Prefix:DR
First Name:MONIKA
Middle Name:GERDA
Last Name:FEALKO
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 1:333 N. FIRST ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-338-8900
Mailing Address - Fax:208-331-2418
Practice Address - Street 1:333 N. FIRST ST
Practice Address - Street 2:SUITE 240
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-338-8900
Practice Address - Fax:208-331-2418
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079854F174400000X
IDM-10332207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808110100Medicaid
OH2386636Medicaid
P00108848OtherRAILROAD MEDICARE
OHH83803Medicare UPIN
ID808110100Medicaid
OH4106451Medicare PIN