MEDICARE: IDAHO UROLOGY CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	M2768	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1598811945	OTHER	ID	CORP NPI

General Provider Information

NPI Number	:	1598811945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO UROLOGY CLINIC, P.A.

Provider Business Mailing Address
First Line	:	1613 12TH AVE RD STE B
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-6183
Country	:	US
Telephone Number	:	208-466-2461
Fax Number	:	208-466-2488

Provider Business Practice Location Address
First Line	:	1613 12TH AVE RD STE B
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-6183
Country	:	US
Telephone Number	:	208-466-2461
Fax Number	:	208-466-2488

Authorized Official
Title or Position	:	OWNER
Name	:	WILFRED E WATKINS
Credential	:	M.D.
Telephone Number	:	208-466-2461

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	11/09/2010

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