Provider Demographics
NPI:1144301664
Name:DARDIS, JAMES W (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:DARDIS
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:83638-1047
Practice Address - Country:US
Practice Address - Phone:208-634-2225
Practice Address - Fax:208-634-7212
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000625OtherBS MVMC
ID53298OtherBC PLMC
IDD7399OtherBC MVMC
ID003664900Medicaid
ID080047434OtherRRMCR
ID000010000624OtherBS PLMC
ID000010000624OtherBS PLMC
ID53298OtherBC PLMC