Provider Demographics
NPI:1063668077
Name:CUMBO, HEATHER FOWLER (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:FOWLER
Last Name:CUMBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7542
Mailing Address - Country:US
Mailing Address - Phone:208-227-2100
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2434
Practice Address - Country:US
Practice Address - Phone:208-750-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-10
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC149697207R00000X
IDM-138722084P0800X
FLME1218922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine