Provider Demographics
NPI:1053469668
Name:CHESTER, EARL CEPHAS JR (MD)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:CEPHAS
Last Name:CHESTER
Suffix:JR
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 1:115 S 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-2106
Mailing Address - Fax:208-232-0432
Practice Address - Street 1:115 S 15TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-2106
Practice Address - Fax:208-232-0432
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3346207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1110276OtherMEDICARE PROVIDER
D73450Medicare UPIN