Provider Demographics
NPI:1902948516
Name:HALL, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:HALL
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 1:190 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 1:211 FOREST ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-5256
Practice Address - Country:US
Practice Address - Phone:208-634-2225
Practice Address - Fax:208-634-7212
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003739000Medicaid
ID000010000858OtherBS SRMC
ID080063338OtherRRMCR
ID000010000860OtherBS PLMC
ID10520OtherBC PLMC
IDD0410OtherBC SMRC
WA135080OtherDEPT OF LABOR WA
ID000010000860OtherBS PLMC
IDD0410OtherBC SMRC