Individual
CHARLES PITTMAN LAWLESS
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1777 EAST CLARK STEET, SUITE 310, POCATELLO, ID 83201-3357
(208) 232-4133
(208) 232-4133
Mailing address
1777 EAST CLARK STEET, SUITE 310, POCATELLO, ID 83201-3357
(208) 232-4133
(208) 232-4133
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
M3434
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010005308
REGENCE BLUE SHIELD
ID
01
—
07302
BLUE CROSS
ID
Enumeration date
03/20/2006
Last updated
07/08/2007
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