Provider Demographics
NPI:1265413017
Name:OWSLEY, FREDRICK MARK (MD)
Entity type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:MARK
Last Name:OWSLEY
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 1:980 W IRONWOOD DR
Mailing Address - Street 2:STE 206
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-664-0165
Mailing Address - Fax:208-664-5695
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:STE 206
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-664-0165
Practice Address - Fax:208-664-5695
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002781300Medicaid
IDG05204Medicare UPIN
ID20006703Medicare PIN