Healthcare Provider Details

I. General information

NPI: 1851591879
Provider Name (Legal Business Name): MICHELLE MAE FRESHWATER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 E OVERLAND RD STE 204
MERIDIAN ID
83642-9048
US

IV. Provider business mailing address

3875 E OVERLAND RD STE 204
MERIDIAN ID
83642-9048
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-3652
  • Fax: 208-367-9188
Mailing address:
  • Phone: 208-343-3652
  • Fax: 208-367-9188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberM-8944
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM-8944
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: