Provider Demographics
NPI:1154732212
Name:LAKY, DEVIN (MD)
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:
Last Name:LAKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3399 E. LOUISE DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-288-2255
Mailing Address - Fax:208-706-2043
Practice Address - Street 1:3399 E LOUISE DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5047
Practice Address - Country:US
Practice Address - Phone:208-288-2255
Practice Address - Fax:208-706-2043
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID390200000X
IDM-13217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program