Healthcare Provider Details

I. General information

NPI: 1770679243
Provider Name (Legal Business Name): CARL FREEMAN WURSTER M.D,F.A.C.S.,F.I.C.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 N COLE RD STE. B
BOISE ID
83704
US

IV. Provider business mailing address

2316 N COLE RD STE. B
BOISE ID
83704
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-6949
  • Fax: 208-342-7008
Mailing address:
  • Phone: 208-345-6949
  • Fax: 208-342-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM-4925
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: