Healthcare Provider Details

I. General information

NPI: 1669430955
Provider Name (Legal Business Name): RANDALL G. LORENZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 SOUTH MAIN STREET
MOSCOW ID
83843
US

IV. Provider business mailing address

623 SOUTH MAIN STREET
MOSCOW ID
83843
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2011
  • Fax: 208-883-1853
Mailing address:
  • Phone: 208-882-2011
  • Fax: 208-883-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34153
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME83125
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG31181
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD11024
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: