Healthcare Provider Details

I. General information

NPI: 1871685321
Provider Name (Legal Business Name): LLOYD E. WITHAM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W IRONWOOD DR
COEUR D ALENE ID
83814-2604
US

IV. Provider business mailing address

1107 W IRONWOOD DR
COEUR D ALENE ID
83814-2604
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-7459
  • Fax: 208-667-2631
Mailing address:
  • Phone: 208-667-7459
  • Fax: 208-667-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM5216
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberM5216
License Number StateID

VIII. Authorized Official

Name: LLOYD E WITHAM
Title or Position: PHYSICIAN
Credential: MD
Phone: 208-667-7459