Provider Demographics
NPI:1871618892
Name:LIFESTAGES OB-GYN PLLC
Entity type:Organization
Organization Name:LIFESTAGES OB-GYN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-442-8038
Mailing Address - Street 1:3908 E FLAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3102
Mailing Address - Country:US
Mailing Address - Phone:208-442-8035
Mailing Address - Fax:208-442-8038
Practice Address - Street 1:3908 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3102
Practice Address - Country:US
Practice Address - Phone:208-442-8035
Practice Address - Fax:208-442-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8105207V00000X
IDM8055207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807138400Medicaid
ID806339500Medicaid
ID806575300Medicaid
ID807138400Medicaid
ID806575300Medicaid
ID1105831Medicare ID - Type UnspecifiedJULIETTE HUGHES
ID806339500Medicaid
ID1109754Medicare ID - Type UnspecifiedDUSTAN HUGHES