Provider Demographics
NPI:1265026660
Name:IDEMA, JOHN PETER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
Last Name:IDEMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 WALL ST STE 203
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-8341
Mailing Address - Country:US
Mailing Address - Phone:719-388-2120
Mailing Address - Fax:
Practice Address - Street 1:6475 WALL ST STE 203
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8341
Practice Address - Country:US
Practice Address - Phone:719-388-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHAD.0000428237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty