Organization
IDAHO DERMATOLOGIC SURGERY & LASER CENTER PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TERI J COTTINGHAM M.D. (OWNER)
(208) 869-2869
Entity
Organization
Contact information
Practice address
1488 N KNIGHTS DR, BOISE, ID 83712-6557
(208) 345-4050
(208) 327-9524
Mailing address
967 E PARKCENTER BLVD # 142, BOISE, ID 83706-6721
(208) 345-4050
(208) 327-9524
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
M-7506
ID
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
M-7506
ID
207NS0135X
Procedural Dermatology Physician
M-7506
ID
261QM2500X
Medical Specialty Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1139318
PTAN
ID
05
—
805151100
—
ID
Enumeration date
07/03/2007
Last updated
02/23/2024
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