Provider Demographics
NPI:1710392410
Name:MEDICAL DIRECTORS OF IDAHO PLLC
Entity Type:Organization
Organization Name:MEDICAL DIRECTORS OF IDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESPONSIBLE PARTY/REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-544-1780
Mailing Address - Street 1:PO BOX 44527
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0527
Mailing Address - Country:US
Mailing Address - Phone:208-384-9022
Mailing Address - Fax:208-947-3465
Practice Address - Street 1:404 N HORTON ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6541
Practice Address - Country:US
Practice Address - Phone:208-466-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty