Provider Demographics
NPI:1861774291
Name:SCHICKER, MICHAEL DAVID (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SCHICKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30544 HIGHWAY 200 STE 102
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5005
Mailing Address - Country:US
Mailing Address - Phone:208-265-9817
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:30544 HIGHWAY 200 STE 102
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852
Practice Address - Country:US
Practice Address - Phone:208-265-9817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60637340207XP3100X, 207XX0005X
IDO0947207XP3100X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8502734Medicaid
ID807920700Medicaid