Provider Demographics
NPI:1225257652
Name:DIABETES AND INTERNAL MEDICINE
Entity Type:Organization
Organization Name:DIABETES AND INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:D'SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-236-1600
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0335
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:2302 E. TERRY STREET
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-236-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11439302Medicare PIN