1629685235 NPI number — MR. MARK MITCHELL ROUBIDOUX II NP-C

Table of content: MR. MARK MITCHELL ROUBIDOUX II NP-C (NPI 1629685235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629685235 NPI number — MR. MARK MITCHELL ROUBIDOUX II NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUBIDOUX
Provider First Name:
MARK
Provider Middle Name:
MITCHELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
NP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629685235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 E NEIDER AVE STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83815-6007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-930-4944
Provider Business Mailing Address Fax Number:
877-376-4040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 WARNER DR STE 4A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-4441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-305-3537
Provider Business Practice Location Address Fax Number:
877-376-4040
Provider Enumeration Date:
09/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  39235 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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