Provider Demographics
NPI:1568410025
Name:JELINEK, JOHN ADAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ADAM
Last Name:JELINEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ADAM
Other - Middle Name:
Other - Last Name:JELINEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:320 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-746-8741
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10275207XX0005X
WAMD 60001068207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA238312OtherWA DEPT OF LABOR & INDUSTRIES
ID77378OtherBLUE CROSS OF ID
ID808097200Medicaid
WA8517518Medicaid
WA8801540Medicare PIN
ID77378OtherBLUE CROSS OF ID