Provider Demographics
NPI:1437563699
Name:FOOT & ANKLE SPECIALISTS OF IDAHO, P.C.
Entity Type:Organization
Organization Name:FOOT & ANKLE SPECIALISTS OF IDAHO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-346-7443
Mailing Address - Street 1:1277 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6126
Mailing Address - Country:US
Mailing Address - Phone:208-346-7443
Mailing Address - Fax:208-346-7442
Practice Address - Street 1:1277 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6126
Practice Address - Country:US
Practice Address - Phone:267-644-6880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-223213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty