Healthcare Provider Details

I. General information

NPI: 1457340481
Provider Name (Legal Business Name): TILDON C ROBINSON IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4424 E FLAMINGO AVE SUITE 110
NAMPA ID
83687
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-288-4700
  • Fax: 208-288-4720
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM8080
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-8080
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: