Provider Demographics
NPI:1750652384
Name:JOHN M LIVINGSTON MD PA
Entity Type:Organization
Organization Name:JOHN M LIVINGSTON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-853-3051
Mailing Address - Street 1:8756 W EMERALD ST
Mailing Address - Street 2:SUITE 136
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4831
Mailing Address - Country:US
Mailing Address - Phone:208-853-3051
Mailing Address - Fax:208-853-3053
Practice Address - Street 1:8756 W EMERALD ST
Practice Address - Street 2:SUITE 136
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4831
Practice Address - Country:US
Practice Address - Phone:208-853-3051
Practice Address - Fax:208-853-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty