Provider Demographics
NPI:1245223809
Name:SONNTAG, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SONNTAG
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 1:5680 W GAGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1326
Mailing Address - Country:US
Mailing Address - Phone:280-377-3937
Mailing Address - Fax:208-377-9455
Practice Address - Street 1:5680 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1326
Practice Address - Country:US
Practice Address - Phone:208-377-3937
Practice Address - Fax:208-377-9455
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2012-06-25
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
IDM4623207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001553800Medicaid
1115823Medicare PIN
B63621Medicare UPIN