Provider Demographics
NPI:1417901638
Name:TORQUATO, JOHN L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:TORQUATO
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 1:265 W. PRAIRIE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8442
Mailing Address - Country:US
Mailing Address - Phone:208-772-7850
Mailing Address - Fax:208-772-2313
Practice Address - Street 1:265 W. PRAIRIE AVE.
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8442
Practice Address - Country:US
Practice Address - Phone:208-772-7850
Practice Address - Fax:208-772-2313
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8058948Medicaid
ID8058948Medicaid
ID42595Medicare ID - Type UnspecifiedPREV #, UPDATING TO NEW