Healthcare Provider Details

I. General information

NPI: 1114961166
Provider Name (Legal Business Name): MARK SCOTT WILLIAMS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

IV. Provider business mailing address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-3291
  • Fax: 208-463-3049
Mailing address:
  • Phone: 208-463-3291
  • Fax: 208-463-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberO-157
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberO-157
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0-157
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: