Provider Demographics
NPI:1558985408
Name:LILJENQUIST, JOHNATHAN BEAU (DO)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:BEAU
Last Name:LILJENQUIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7549
Mailing Address - Country:US
Mailing Address - Phone:208-522-7310
Mailing Address - Fax:
Practice Address - Street 1:2442 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7549
Practice Address - Country:US
Practice Address - Phone:208-522-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine