Provider Demographics
NPI:1053413153
Name:PHANEUF, JOSEPH D (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:PHANEUF
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-2072
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-3260
Practice Address - Fax:509-474-2245
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1103936Medicaid
121414OtherL & I
WAG000362000OtherMEDICARE GROUP NUMBER
WACG4026OtherMEDCIARE RR GROUP
WAP00395895OtherMEDICARE RR NUMBER
WA8473381Medicaid
E60936Medicare UPIN
WA1103936Medicaid
WA8473381Medicaid