Healthcare Provider Details

I. General information

NPI: 1114086048
Provider Name (Legal Business Name): LARRY DAVID BOMSTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 WASHINGTON ST
MONTPELIER ID
83254-1544
US

IV. Provider business mailing address

467 WASHINGTON ST
MONTPELIER ID
83254-1544
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-0072
  • Fax: 208-847-0077
Mailing address:
  • Phone: 208-847-0072
  • Fax: 208-847-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5549
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: