Basic Information
Provider Information | |||||||||
NPI: | 1053493809 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DJ MARC CARDINAL, MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2896 | ||||||||
Address2: |   | ||||||||
City: | IDAHO FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 834032896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085234906 | ||||||||
FaxNumber: | 2085232025 | ||||||||
Practice Location | |||||||||
Address1: | 98 POPLAR ST | ||||||||
Address2: |   | ||||||||
City: | BLACKFOOT | ||||||||
State: | ID | ||||||||
PostalCode: | 832211758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087853810 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 10/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARDINAL | ||||||||
AuthorizedOfficialFirstName: | DJ | ||||||||
AuthorizedOfficialMiddleName: | MARC | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2087853810 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | DG2308 | 01 |   | RAILROAD MEDICARE GROUP | OTHER | 806651100 | 05 | ID |   | MEDICAID |