Provider Demographics
NPI:1104040104
Name:ALLEN, JEFFREY WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WARREN
Last Name:ALLEN
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:1440 E MULLAN AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9064
Practice Address - Country:US
Practice Address - Phone:208-625-4900
Practice Address - Fax:208-625-4901
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12843207RH0003X
TN42409207RH0003X
MS20219207RH0003X
ARE5912207RH0003X
CAA119074207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS$$$$$$$$$OtherBCBS MS
TN3001657Medicaid
TN4182885OtherBCBS TN
AR168595001Medicaid
MS07903340Medicaid
AR5H477C422Medicare PIN
MS512I820001Medicare PIN
7619266OtherCIGNA
AR1104040104OtherBCBS AR
CAFT005ZMedicare PIN
TN3001657Medicare PIN
9023188OtherAETNA