Provider Demographics
NPI:1841246279
Name:BUONCRISTIANI, ANTHONY MAISIN (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MAISIN
Last Name:BUONCRISTIANI
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:PO BOX 1332
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83353-1332
Mailing Address - Country:US
Mailing Address - Phone:208-622-3311
Mailing Address - Fax:208-622-4919
Practice Address - Street 1:660 2ND AVE S
Practice Address - Street 2:UNIT A
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-622-3312
Practice Address - Fax:208-622-4919
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9501207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00381131OtherRR MEDICARE
ID807513700Medicaid
ID5897630001Medicare NSC
ID1134128Medicare PIN
I64814Medicare UPIN