Provider Demographics
NPI:1669455770
Name:HARTWIG, ROXIE KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROXIE
Middle Name:KIM
Last Name:HARTWIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ROXIE
Other - Middle Name:KIM
Other - Last Name:CUNNINGHAM-HARTWIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540-0367
Mailing Address - Country:US
Mailing Address - Phone:208-843-2271
Mailing Address - Fax:208-621-4995
Practice Address - Street 1:111 BEVER GRADE RD
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540-0367
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:208-621-4995
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045536207Q00000X
IDM-14801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1245640606OtherCORP NPI