Provider Demographics
NPI:1114086048
Name:BOMSTA, LARRY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DAVID
Last Name:BOMSTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1544
Mailing Address - Country:US
Mailing Address - Phone:208-847-0072
Mailing Address - Fax:208-847-0077
Practice Address - Street 1:467 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1544
Practice Address - Country:US
Practice Address - Phone:208-847-0072
Practice Address - Fax:208-847-0077
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5549-1OtherBLUE CROSS OF IDAHO
ID000010004905OtherBLUE SHIELD OF IDAHO
ID000010004905OtherBLUE SHIELD OF IDAHO
1122606Medicare ID - Type Unspecified