Provider Demographics
NPI:1124357645
Name:ROBERT L. DAVIDSON, M.D. PLLC
Entity Type:Organization
Organization Name:ROBERT L. DAVIDSON, M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LANTZ
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-890-9539
Mailing Address - Street 1:13601 W MCMILLAN RD
Mailing Address - Street 2:SUITE 102-311
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2071
Mailing Address - Country:US
Mailing Address - Phone:208-890-2539
Mailing Address - Fax:208-939-2698
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 1245
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-890-2539
Practice Address - Fax:208-939-2698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7907207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003661400Medicaid
IDA06216Medicare UPIN