Provider Demographics
NPI:1710941026
Name:AGEE, JON MOORE (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MOORE
Last Name:AGEE
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:PO BOX 742941
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4846
Practice Address - Country:US
Practice Address - Phone:208-459-0028
Practice Address - Fax:208-459-0380
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003570900Medicaid
ID000010004422OtherREGENCE BLUE SHIELD
ID59725OtherBLUE CROSS OF IDAHO
ID59725OtherBLUE CROSS OF IDAHO