Provider Demographics
NPI:1093717787
Name:ALLEN, RICHARD MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 23RD AVE
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6350
Mailing Address - Country:US
Mailing Address - Phone:208-743-3688
Mailing Address - Fax:208-743-5162
Practice Address - Street 1:1630 23RD AVE
Practice Address - Street 2:SUITE 1001
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6350
Practice Address - Country:US
Practice Address - Phone:208-743-3688
Practice Address - Fax:208-743-5162
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-143213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0027887Medicaid
ID000010015686OtherREGENCE BLUESHIELD OF ID
IDP9186OtherBLUE CROSS OF IDAHO
ID5395420001Medicare NSC
ID000010015686OtherREGENCE BLUESHIELD OF ID
IDP9186OtherBLUE CROSS OF IDAHO