Provider Demographics
NPI:1154310597
Name:FOOTE, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FOOTE
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-452-3111
Mailing Address - Fax:208-452-3666
Practice Address - Street 1:910 NW 16TH STREET
Practice Address - Street 2:STE 205
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-3111
Practice Address - Fax:208-452-3666
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10864207X00000X
ORMD26309207X00000X
OR26309207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79508Medicare UPIN
ID807391300Medicaid
OR134124Medicare ID - Type Unspecified
OR005776Medicaid