Organization
CHARLES P. LAWLESS, M.D., P.A.
Active
Other names
WALT'S OPTICAL SHOP
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHARLES PITTMAN LAWLESS M.D. (PRESIDENT)
(208) 232-4133
Entity
Organization
Contact information
Practice address
1777 E CLARK ST STE 310, POCATELLO, ID 83201-3357
(208) 232-4133
(208) 233-5736
Mailing address
1777 E CLARK ST STE 310, POCATELLO, ID 83201-3357
(208) 232-4133
(208) 233-5736
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M-3434
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010005308
REGENCE BLUE SHIELD OF ID
ID
01
—
07302
BLUE CROSS OF IDAHO
ID
Enumeration date
05/04/2007
Last updated
12/03/2007
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