Provider Demographics
NPI:1447512348
Name:LIDSTROM, MATTHEW SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:LIDSTROM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6300
Mailing Address - Fax:208-625-6920
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6300
Practice Address - Fax:208-625-6920
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORPG158433207R00000X
WAMDRE.ML.604727952085R0202X
ORMD1873622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine