Provider Demographics
NPI:1144213554
Name:CREE, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CREE
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:POCATELLO (ISU) FAMILY MEDICINE
Mailing Address - Street 2:465 MEMORIAL DRIVE
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-4700
Mailing Address - Fax:208-282-4696
Practice Address - Street 1:POCATELLO (ISU) FAMILY MEDICINE
Practice Address - Street 2:465 MEMORIAL DRIVE
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-4700
Practice Address - Fax:208-282-4696
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA27523Medicare UPIN
ID1134468Medicare ID - Type Unspecified