Provider Demographics
NPI:1750791471
Name:SIBBERNSEN, ERIK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:DAVID
Last Name:SIBBERNSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-813-8752
Mailing Address - Fax:
Practice Address - Street 1:3101 E STATE ST STE 2120
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-473-3275
Practice Address - Fax:208-473-3276
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-17816207R00000X
IN01075639A171000000X
ORPG168052390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program