Healthcare Provider Details

I. General information

NPI: 1053306100
Provider Name (Legal Business Name): ALLEN R SKIDMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16528 E DESMET CT
SPOKANE VALLEY WA
99216-3522
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-944-9440
  • Fax: 509-227-7070
Mailing address:
  • Phone: 866-747-2455
  • Fax: 509-227-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26688
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00046129
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: