Healthcare Provider Details

I. General information

NPI: 1861774291
Provider Name (Legal Business Name): MICHAEL DAVID SCHICKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200 STE 102
PONDERAY ID
83852
US

IV. Provider business mailing address

30544 HIGHWAY 200 STE 102
PONDERAY ID
83852-5005
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-9817
  • Fax:
Mailing address:
  • Phone: 208-265-9817
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberO0947
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberO0947
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberOP60637340
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOP60637340
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: