Provider Demographics
NPI:1871794446
Name:FORD, PHILIP DAVID (PHD, ATC, LAT)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DAVID
Last Name:FORD
Suffix:
Gender:M
Credentials:PHD, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1710
Mailing Address - Country:US
Mailing Address - Phone:208-426-4278
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-1710
Practice Address - Country:US
Practice Address - Phone:208-426-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT5272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAT527OtherIDAHO STATE BOARD OF MEDICINE