Basic Information
| Provider Information | |||||||||
| NPI: | 1134342264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEER POINT FAMILY PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4979 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837114979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083227284 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Practice Location | |||||||||
| Address1: | 6023 N EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837130997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083227284 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | TUBBS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083227284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 002643400 | 05 | ID | MEDICAID | 000010028455 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER |