Provider Demographics
NPI:1619904638
Name:STAGG, DOUGLAS L (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:STAGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 101
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8100
Practice Address - Fax:208-814-8900
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-09-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM35282083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003949000Medicaid
IDC47905Medicare UPIN
ID003949000Medicaid