Individual
DR. LARRY DAVID BOMSTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
467 WASHINGTON ST, MONTPELIER, ID 83254-1544
(208) 847-0072
(208) 847-0077
Mailing address
467 WASHINGTON ST, MONTPELIER, ID 83254-1544
(208) 847-0072
(208) 847-0077
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5549
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010004905
BLUE SHIELD OF IDAHO
ID
01
—
5549-1
BLUE CROSS OF IDAHO
ID
Enumeration date
12/06/2006
Last updated
07/08/2007
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