Healthcare Provider Details

I. General information

NPI: 1093717787
Provider Name (Legal Business Name): RICHARD MICHAEL ALLEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 23RD AVE SUITE 1001
LEWISTON ID
83501-6350
US

IV. Provider business mailing address

1630 23RD AVE SUITE 1001
LEWISTON ID
83501-6350
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-3688
  • Fax: 208-743-5162
Mailing address:
  • Phone: 208-743-3688
  • Fax: 208-743-5162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP-143
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: