Provider Demographics
NPI:1871112094
Name:DIRECT DOCTOR CARE PLLC
Entity type:Organization
Organization Name:DIRECT DOCTOR CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-965-4899
Mailing Address - Street 1:509 S MIDDLETON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-6047
Mailing Address - Country:US
Mailing Address - Phone:208-965-4899
Mailing Address - Fax:
Practice Address - Street 1:509 S MIDDLETON RD STE 105
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-6047
Practice Address - Country:US
Practice Address - Phone:208-668-2080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty