=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851591879
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE MAE FRESHWATER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3875 E OVERLAND RD STE 204
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-9048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-343-3652
-----------------------------------------------------
Fax | 208-367-9188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3875 E OVERLAND RD STE 204
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-9048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-343-3652
-----------------------------------------------------
Fax | 208-367-9188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | M-8944
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | M-8944
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------