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>> Internal Medicine >> Allopathic & Osteopathic Physicians

Registrant NPI Number: 1699883447

Individual Registrant:
Gender: M
Not Sole Proprietor

Location and contact information for practice:
910 NW 16TH ST STE 102  FRUITLAND, ID 83619-2265 US
Tel: 208-452-8015  Fax: 208-452-8055

Contact information for business:
Tel: 208-452-8015  Fax: 208-452-8055

Registration Information:
NPI: 1699883447
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
N207R00000XAllopathic & Osteopathic Physicians
Internal Medicine
Y207R00000XAllopathic & Osteopathic Physicians
Internal Medicine

Legacy codes, insurance codes and state license numbers:



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