Healthcare Provider Details

I. General information

NPI: 1902809205
Provider Name (Legal Business Name): LAYNE D. ROBERTS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3138
US

IV. Provider business mailing address

2000 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3138
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-1500
  • Fax: 208-587-3180
Mailing address:
  • Phone: 208-587-1500
  • Fax: 208-587-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-91
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: