Individual
DR. ANANDA WALALIYADDA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1448 E CENTER ST, SUITE E, POCATELLO, ID 83201-4132
(208) 234-1300
(208) 234-1333
Mailing address
1448 E CENTER ST, SUITE E, POCATELLO, ID 83201-4132
(208) 234-1300
(208) 234-1333
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M8731
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
J9521
BLUE CROSS
ID
Enumeration date
08/22/2005
Last updated
06/29/2022
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