Provider Demographics
NPI:1548581390
Name:FENSTERMAKER, JOHN ABRAHAM (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ABRAHAM
Last Name:FENSTERMAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1951 BENCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2013
Mailing Address - Country:US
Mailing Address - Phone:208-238-1000
Mailing Address - Fax:208-238-0009
Practice Address - Street 1:1951 BENCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2013
Practice Address - Country:US
Practice Address - Phone:208-238-1000
Practice Address - Fax:208-238-0009
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-1113207Q00000X
IDO-0623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20003139Medicare PIN