Provider Demographics
NPI:1578552139
Name:PARENT, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:PARENT
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 1:1630 23RD AVE
Mailing Address - Street 2:SUITE 701
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6350
Mailing Address - Country:US
Mailing Address - Phone:208-743-3998
Mailing Address - Fax:208-746-4879
Practice Address - Street 1:1630 23RD AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6350
Practice Address - Country:US
Practice Address - Phone:208-743-3998
Practice Address - Fax:208-746-4879
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4475174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001224600Medicaid
8807789Medicare PIN
P00186297Medicare PIN
1115108Medicare PIN