Provider Demographics
NPI:1942211818
Name:SHOWALTER, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:SHOWALTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-383-0201
Mailing Address - Fax:208-489-4300
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4566
Practice Address - Country:US
Practice Address - Phone:208-383-0201
Practice Address - Fax:208-489-4300
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6652207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000904Medicare PIN