Provider Demographics
NPI:1497960983
Name:JAN DEBLIECK MD PA
Entity Type:Organization
Organization Name:JAN DEBLIECK MD PA
Other - Org Name:DEBLIECK DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBLIECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-939-5030
Mailing Address - Street 1:13176 W PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-939-5030
Mailing Address - Fax:208-939-1892
Practice Address - Street 1:13176 W PERSIMMON LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-939-5030
Practice Address - Fax:208-939-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7045207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1368446Medicare Oscar/Certification
IDG37337Medicare UPIN