Provider Demographics
NPI:1811978778
Name:HUMPHREY, CARL SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:SCOTT
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:SCOTT
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3381 W BAVARIA STREET
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5341
Mailing Address - Country:US
Mailing Address - Phone:208-639-4800
Mailing Address - Fax:208-639-4801
Practice Address - Street 1:3381 W BAVARIA STREET
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5341
Practice Address - Country:US
Practice Address - Phone:208-639-4800
Practice Address - Fax:208-639-4801
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9563207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A905630Medicare ID - Type Unspecified
I36275Medicare UPIN