Provider Demographics
NPI:1265651566
Name:CHOUTKA, ONDREJ (MD)
Entity Type:Individual
Prefix:
First Name:ONDREJ
Middle Name:
Last Name:CHOUTKA
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:208-367-4035
Mailing Address - Fax:208-367-7111
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-367-4035
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57009091207T00000X
KY43915207T00000X
IDM-13330207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100170950Medicaid
WV3810020999Medicaid
OH0050167Medicaid
KYK007810Medicare PIN