Healthcare Provider Details

I. General information

NPI: 1871904698
Provider Name (Legal Business Name): MATTHEW MORS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6052 W STATE ST
BOISE ID
83703-2739
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-7799
  • Fax:
Mailing address:
  • Phone: 208-955-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number5101021036
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberO-1265
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: