Provider Demographics
NPI:1912984139
Name:MAHESWARAN, MURALI (DO)
Entity Type:Individual
Prefix:
First Name:MURALI
Middle Name:
Last Name:MAHESWARAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:450 FALLS AVE STE 202
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-2307
Practice Address - Country:US
Practice Address - Phone:208-933-0040
Practice Address - Fax:208-933-0042
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-20002084S0012X
MO20040014632084N0400X
WAOP00022742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263563OtherLABOR & INDUSTRIES
MO129441Medicare UPIN
WA8892577Medicare PIN
MO129441Medicare UPIN