Provider Demographics
NPI:1770679243
Name:WURSTER, CARL FREEMAN (MD,FACS,FICS)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:FREEMAN
Last Name:WURSTER
Suffix:
Gender:M
Credentials:MD,FACS,FICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 N COLE RD
Mailing Address - Street 2:STE. B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-345-6949
Mailing Address - Fax:208-342-7008
Practice Address - Street 1:2316 N COLE RD
Practice Address - Street 2:STE. B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-345-6949
Practice Address - Fax:208-342-7008
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1118296Medicare ID - Type Unspecified