Provider Demographics
NPI:1710978697
Name:FRIESEN, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FRIESEN
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 1:6635 COMANCHE ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7523
Mailing Address - Country:US
Mailing Address - Phone:208-267-1718
Mailing Address - Fax:208-267-7739
Practice Address - Street 1:6635 COMANCHE ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7523
Practice Address - Country:US
Practice Address - Phone:208-267-1718
Practice Address - Fax:208-267-7739
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G96364Medicare UPIN
ID13-1822Medicare Oscar/Certification
ID1124264Medicare ID - Type UnspecifiedPART B