Provider Demographics
NPI:1598750838
Name:FORNAROTTO, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:FORNAROTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:246 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3356
Mailing Address - Country:US
Mailing Address - Phone:208-234-4100
Mailing Address - Fax:208-234-4192
Practice Address - Street 1:246 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3356
Practice Address - Country:US
Practice Address - Phone:208-234-4100
Practice Address - Fax:208-234-4192
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6417207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002738900Medicaid
IDB4435Medicare UPIN