Healthcare Provider Details

I. General information

NPI: 1417184409
Provider Name (Legal Business Name): MARK NOBLE SCHWENDIMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

IV. Provider business mailing address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax:
Mailing address:
  • Phone: 208-884-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberO1018
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: