Healthcare Provider Details

I. General information

NPI: 1891767745
Provider Name (Legal Business Name): GLENN D ZAUSMER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POLE LINE RD W SUITE 301
TWIN FALLS ID
83301-5814
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8700
  • Fax: 208-933-4914
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101012942
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberDO154497
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: