Provider Demographics
NPI:1053365494
Name:IGIC, PETAR G (MD)
Entity type:Individual
Prefix:
First Name:PETAR
Middle Name:G
Last Name:IGIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W CURTISIAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0107
Practice Address - Country:US
Practice Address - Phone:208-302-0000
Practice Address - Fax:208-302-0055
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI49209-20207RC0000X
WI49209-020207RC0001X
IDM-17812207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053365494Medicaid
WIK400380728Medicare PIN