Provider Demographics
NPI:1760486138
Name:HIGGINBOTHAM, RONALD SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:SCOTT
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7685 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9018
Mailing Address - Country:US
Mailing Address - Phone:208-376-2522
Mailing Address - Fax:208-375-5860
Practice Address - Street 1:7685 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9018
Practice Address - Country:US
Practice Address - Phone:208-376-2522
Practice Address - Fax:208-375-5860
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-50207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1300741Medicare ID - Type Unspecified
IDD33616Medicare UPIN