Provider Demographics
NPI:1437130515
Name:SULE, J DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:DAVID
Last Name:SULE
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 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-758-4100
Mailing Address - Fax:208-782-3752
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-758-4100
Practice Address - Fax:208-782-3752
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042458174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000718891AMedicaid
GAF84951Medicare UPIN
GA35BDDXJMedicare ID - Type Unspecified