Provider Demographics
NPI:1619977600
Name:LILJENQUIST, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:LILJENQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3910 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-522-2996
Mailing Address - Fax:208-523-3318
Practice Address - Street 1:2220 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7542
Practice Address - Country:US
Practice Address - Phone:208-522-2996
Practice Address - Fax:208-523-6025
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4220207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804012300OtherHEALTHY CONNECTIONS
ID25852OtherBLUESHIELD OF IDAHO
ID113798100OtherWYOMING CONSULTEC EDS
ID002530600Medicaid
ID110008760OtherRAILROAD MEDICARE
DE34512OtherBLUECROSS OF IDAHO
ID002530600Medicaid
ID25852OtherBLUESHIELD OF IDAHO