Ivan D Petrich, DO

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

2019-01392 Issued in NC

Practice address

90 Hope Dr
Mountain Home Afb, ID 83648-1057

Phone

(208) 828-7900

NPI assigned

May 26, 2016

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1464220800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1757635200000",
    "number": "1639527096",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 HOPE DR",
            "city": "MOUNTAIN HOME AFB",
            "state": "ID",
            "postal_code": "836481057",
            "telephone_number": "208-828-7900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 HOPE DR",
            "city": "MOUNTAIN HOME AFB",
            "state": "ID",
            "postal_code": "836481057",
            "telephone_number": "208-828-7900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETRICH",
        "first_name": "IVAN",
        "middle_name": "D",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-05-26",
        "last_updated": "2025-09-12",
        "certification_date": "2025-09-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2083A0100X",
            "taxonomy_group": "",
            "desc": "Preventive Medicine, Aerospace Medicine",
            "state": "NC",
            "license": "2019-01392",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NC",
            "license": "2019-01392",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nathan Tuaefu Palmer, M.D.
• Cleo Patrick, PHD, LCSW, LICSW
• Alyssa May Perez, PA-C
• Joseph Richard Perry
• Cody Peterson, O.D.
• Kayla Azalea Pope, PA-C
• Stephen Sterling Potter, DDS
• Amanda Marie Ralston, PA
• Marissa Redding, COTA
• Dennis Jacob Reuter, IDMT

• Family Medicine Physician in Mountain Home Afb, ID
• Providers in Mountain Home Afb, ID by specialty
• Family Medicine Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.