Provider Demographics
NPI:1679527717
Name:PADAVANIJA, PHATAMA (MD)
Entity type:Individual
Prefix:
First Name:PHATAMA
Middle Name:
Last Name:PADAVANIJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 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:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:725 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5800
Practice Address - Country:US
Practice Address - Phone:208-814-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17531207RH0003X
IDM-11228207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009997775Medicaid
AL009997765Medicaid
AL009998765Medicaid
F61894Medicare UPIN
AL009998765Medicaid
4248810003Medicare NSC
051555666Medicare PIN
AL009997775Medicaid
ID20000262Medicare PIN
4248810004Medicare NSC