Provider Demographics
NPI:1417943622
Name:JEPPSON, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:JEPPSON
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 1:901 N CURTIS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1394
Mailing Address - Country:US
Mailing Address - Phone:208-378-0080
Mailing Address - Fax:208-378-0259
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1394
Practice Address - Country:US
Practice Address - Phone:208-378-0080
Practice Address - Fax:208-378-0259
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6607207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215061734Medicaid
ID1215061734Medicaid
ID1130829Medicare PIN