Provider Demographics
NPI:1255449898
Name:HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY, PC
Entity type:Organization
Organization Name:HIGH VALLEY DERMATOLOGY & DERMATOLOGIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-525-4888
Mailing Address - Street 1:2375 E SUNNYSIDE RD STE J
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8281
Mailing Address - Country:US
Mailing Address - Phone:208-525-4888
Mailing Address - Fax:208-525-4885
Practice Address - Street 1:2375 E SUNNYSIDE RD STE J
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8281
Practice Address - Country:US
Practice Address - Phone:208-525-4888
Practice Address - Fax:208-525-4885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7012207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1400773Medicare ID - Type UnspecifiedMEDICARE GROUP #