Provider Demographics
NPI:1366560971
Name:IDAHO FALLS PEDIATRICS
Entity type:Organization
Organization Name:IDAHO FALLS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RON
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-4600
Mailing Address - Street 1:3067 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-1273
Mailing Address - Country:US
Mailing Address - Phone:208-522-4600
Mailing Address - Fax:208-552-7521
Practice Address - Street 1:3067 EAGLE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-1273
Practice Address - Country:US
Practice Address - Phone:208-522-4600
Practice Address - Fax:208-552-7521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM72712080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty