Basic Information
Provider Information | |||||||||
NPI: | 1497931893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POIRIER | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5429 N RED HILLS AVE | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836467657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085598212 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5610 W GAGE ST STE A | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 83706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085018955 | ||||||||
FaxNumber: | 2083673332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2008 | ||||||||
LastUpdateDate: | 09/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 60425 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | O-1172 | ID | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | DO188924 | OR | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | Q6684 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 372000501 | 05 | TX |   | MEDICAID | 372000502 | 01 | TX | CSHCN | OTHER |