Basic Information
| Provider Information | |||||||||
| NPI: | 1487602330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SACCOMANDO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D., P.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 W FRANKLIN ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083452212 | ||||||||
| FaxNumber: | 2083452282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083452212 | ||||||||
| FaxNumber: | 2083452282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | M9565 | ID | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | M9565 | ID | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 500664707 | 05 | OR | MEDICAID | 807512200 | 05 | ID | MEDICAID |