Provider Demographics
NPI:1497715866
Name:ROSER, LOUIS A JR (MD)
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:A
Last Name:ROSER
Suffix:JR
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-5200
Mailing Address - Fax:208-302-5225
Practice Address - Street 1:1880 JUDITH LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3185
Practice Address - Country:US
Practice Address - Phone:208-302-5200
Practice Address - Fax:208-302-5225
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7135207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8043004Medicaid
ID11129121Medicare PIN
ID804300400Medicaid
1124492Medicare ID - Type UnspecifiedCIGNA
1124493Medicare ID - Type UnspecifiedCIGNA
G50619Medicare UPIN
1124491Medicare ID - Type UnspecifiedCIGNA
ID8043004Medicaid