Basic Information
| Provider Information | |||||||||
| NPI: | 1144275694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LANTZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 E LOUISE DR STE 195 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088468335 | ||||||||
| FaxNumber: | 2088468336 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 E LOUISE DR STE 195 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088468335 | ||||||||
| FaxNumber: | 2088468336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | M7907 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 174400000X | M7907 | ID | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 003661400 | 05 | ID | MEDICAID |