Provider Demographics
NPI:1497784219
Name:BOUGHTON, JANICE (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:BOUGHTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3056
Mailing Address - Country:US
Mailing Address - Phone:509-334-8567
Mailing Address - Fax:208-883-6551
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:509-334-8567
Practice Address - Fax:208-883-6551
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025772207R00000X
IDM-6527207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002641100Medicaid
WA8116196Medicaid
ID002641100Medicaid
WA8116196Medicaid
ID1130702Medicare ID - Type UnspecifiedMEDICAIRE OF IDAHO