Provider Demographics
NPI:1275735045
Name:PICKETT, JAMES WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIAM
Last Name:PICKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:220 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-5068
Mailing Address - Country:US
Mailing Address - Phone:208-766-2600
Mailing Address - Fax:208-766-4258
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-5068
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:208-766-4258
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0838207Q00000X
AZ5012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine