Provider Demographics
NPI:1851591879
Name:FRESHWATER, MICHELLE MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MAE
Last Name:FRESHWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:115 W MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7302
Mailing Address - Country:US
Mailing Address - Phone:208-343-3652
Mailing Address - Fax:208-367-9188
Practice Address - Street 1:115 W MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7302
Practice Address - Country:US
Practice Address - Phone:208-343-3652
Practice Address - Fax:208-367-9188
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-8944208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice