Provider Demographics
NPI:1639123490
Name:FISHBURN, JON R (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:FISHBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 N CURTIS RD
Mailing Address - Street 2:STE 205
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1336
Mailing Address - Country:US
Mailing Address - Phone:208-373-1200
Mailing Address - Fax:
Practice Address - Street 1:999 N CURTIS RD
Practice Address - Street 2:STE 205
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1336
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7225207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30049Medicare UPIN