Provider Demographics
NPI:1114910296
Name:JEPPSON, MELVIN TERRY (MD)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:TERRY
Last Name:JEPPSON
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 1:1501 HILAND AVE
Mailing Address - Street 2:SUITE B1
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2682
Mailing Address - Country:US
Mailing Address - Phone:208-878-2229
Mailing Address - Fax:208-878-4599
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-878-2229
Practice Address - Fax:208-878-4599
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2021-06-17
Deactivation Date:2006-04-03
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
IDM5646207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002663900Medicaid
IDF05952Medicare ID - Type Unspecified