Provider Demographics
NPI:1609842723
Name:PAKULA, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:PAKULA
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 1:222 SOUTHWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2703
Mailing Address - Country:US
Mailing Address - Phone:208-746-3500
Mailing Address - Fax:208-746-6423
Practice Address - Street 1:222 SOUTHWAY
Practice Address - Street 2:SUITE B
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2703
Practice Address - Country:US
Practice Address - Phone:208-746-3500
Practice Address - Fax:208-746-6423
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4761208800000X
WA14070208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016252Medicaid
ID1116463Medicare ID - Type Unspecified
WAAB07441Medicare ID - Type Unspecified
WA1016252Medicaid