Provider Demographics
NPI:1144275694
Name:DAVIDSON, ROBERT LANTZ (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LANTZ
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3525 E LOUISE DR STE 195
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6303
Mailing Address - Country:US
Mailing Address - Phone:208-846-8335
Mailing Address - Fax:208-846-8336
Practice Address - Street 1:3525 E LOUISE DR STE 195
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-846-8335
Practice Address - Fax:208-846-8336
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7907207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003661400Medicaid
IDA06216Medicare UPIN
ID003661400Medicaid