Provider Demographics
NPI:1043207418
Name:MCNULTY, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S 8TH ST
Mailing Address - Street 2:ST MARIES FAMILY MEDICINE
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1813
Mailing Address - Country:US
Mailing Address - Phone:208-245-2591
Mailing Address - Fax:208-245-5246
Practice Address - Street 1:229 S 8TH ST
Practice Address - Street 2:ST MARIES FAMILY MEDICINE
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1813
Practice Address - Country:US
Practice Address - Phone:208-245-2591
Practice Address - Fax:208-245-5246
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7646207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID27805OtherBLUE CROSS OF ID
ID000010000790OtherREGENCE BS OF ID
MT1043207418Medicaid
WA8343854Medicaid
WA124834OtherDEPT OF LABOR & INDUSTRIE
ID1140510Medicare PIN
ID11405102Medicare PIN
20033843Medicare PIN
1140510Medicare Oscar/Certification
ID1373881Medicare Oscar/Certification
ID000010000790OtherREGENCE BS OF ID
WA124834OtherDEPT OF LABOR & INDUSTRIE
WA8343854Medicaid