Healthcare Provider Details

I. General information

NPI: 1821034562
Provider Name (Legal Business Name): WILLIAM BRAD SPEAKMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BANNOCK ST
MALAD CITY ID
83252-5068
US

IV. Provider business mailing address

220 BANNOCK ST
MALAD CITY ID
83252-5068
US

V. Phone/Fax

Practice location:
  • Phone: 208-766-2600
  • Fax: 208-766-4258
Mailing address:
  • Phone: 208-766-2600
  • Fax: 208-766-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-240
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: