Provider Demographics
NPI:1619977972
Name:ISHAM, STEPHEN A (DPM MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:ISHAM
Suffix:
Gender:M
Credentials:DPM MD
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Mailing Address - Street 1:101 W IRONWOOD DR
Mailing Address - Street 2:STE 131
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1409
Mailing Address - Country:US
Mailing Address - Phone:208-666-0605
Mailing Address - Fax:208-666-0916
Practice Address - Street 1:101 W IRONWOOD DR
Practice Address - Street 2:STE 131
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-1409
Practice Address - Country:US
Practice Address - Phone:208-666-0605
Practice Address - Fax:208-666-0916
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDP-76213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805796500Medicaid
ID805796500Medicaid
ID1350800Medicare ID - Type Unspecified
ID1061340001Medicare NSC