Healthcare Provider Details

I. General information

NPI: 1831264878
Provider Name (Legal Business Name): LLOYD D STOLWORTHY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 NW 1ST STREET
MERIDIAN ID
83642
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-9393
  • Fax: 208-888-9525
Mailing address:
  • Phone: 208-955-6522
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM8815
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: