Healthcare Provider Details

I. General information

NPI: 1083691398
Provider Name (Legal Business Name): DAVID LAXSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 01/04/2022
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DRIVE
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 640
BOISE ID
83701-0640
US

V. Phone/Fax

Practice location:
  • Phone: 208-727-8710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number26977
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM-15593
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: