Provider Demographics
NPI:1114977600
Name:FRIZZELL, ROY TYLER (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:TYLER
Last Name:FRIZZELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R
Other - Middle Name:TYLER
Other - Last Name:FRIZZELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:222 N 2ND ST
Practice Address - Street 2:STE 307
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6109
Practice Address - Country:US
Practice Address - Phone:208-344-1000
Practice Address - Fax:208-344-1331
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6824207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000299Medicare PIN