Provider Demographics
NPI:1841267747
Name:NORRIS, THADDEUS MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:MICHAEL
Last Name:NORRIS
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 1:2000 S MYERS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4008
Mailing Address - Country:US
Mailing Address - Phone:503-704-1415
Mailing Address - Fax:
Practice Address - Street 1:215 W 35TH ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-6520
Practice Address - Country:US
Practice Address - Phone:503-704-2415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMV-0023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMV-0023OtherMEDICAL LICENSE
OR00WCBCQBMedicare ID - Type Unspecified
OR241364Medicaid