Provider Demographics
NPI:1336119932
Name:CHISHOLM, DONALD ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ROBERT
Last Name:CHISHOLM
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 1:920 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2463
Mailing Address - Country:US
Mailing Address - Phone:208-667-4557
Mailing Address - Fax:208-765-2887
Practice Address - Street 1:920 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2463
Practice Address - Country:US
Practice Address - Phone:208-667-4557
Practice Address - Fax:208-765-2887
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4527207Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003641200Medicaid
ID1115382Medicare ID - Type Unspecified
IDC36909Medicare UPIN