Provider Demographics
NPI:1306834643
Name:DAHLIN, JAN OLOF (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:OLOF
Last Name:DAHLIN
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 1:1118 NW 16TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2271
Mailing Address - Country:US
Mailing Address - Phone:208-452-2510
Mailing Address - Fax:208-452-2513
Practice Address - Street 1:1118 NW 16TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2271
Practice Address - Country:US
Practice Address - Phone:208-452-2510
Practice Address - Fax:208-452-2513
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6608207X00000X
ORMD13079207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR266148Medicaid
OR121747Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
ID1140903Medicare ID - Type UnspecifiedPERFORMING PROVIDER NUMBE
OR266148Medicaid