Healthcare Provider Details

I. General information

NPI: 1588863591
Provider Name (Legal Business Name): DOCTORS CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 GIFFORD AVE
AMERICAN FALLS ID
83211-1314
US

IV. Provider business mailing address

590 GIFFORD AVE
AMERICAN FALLS ID
83211-1314
US

V. Phone/Fax

Practice location:
  • Phone: 208-226-5147
  • Fax: 208-226-7002
Mailing address:
  • Phone: 208-226-5147
  • Fax: 208-226-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM3687
License Number StateID

VIII. Authorized Official

Name: DR. DEAN L WILLIAMS
Title or Position: MD
Credential: MD
Phone: 208-226-5147