Healthcare Provider Details

I. General information

NPI: 1154976983
Provider Name (Legal Business Name): IDAHO EAR CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 N SUMMERBROOK AVE
MERIDIAN ID
83642-8749
US

IV. Provider business mailing address

1209 N SUMMERBROOK AVE STE 100
MERIDIAN ID
83642-8750
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-5823
  • Fax: 208-938-5306
Mailing address:
  • Phone: 208-938-5823
  • Fax: 208-938-5306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES V CRAWFORD
Title or Position: OWNER
Credential: MD
Phone: 208-938-5823