Provider Demographics
NPI:1790838662
Name:JOHN FORNAROTTO PLLC
Entity Type:Organization
Organization Name:JOHN FORNAROTTO PLLC
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:FORNAROTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-234-4100
Mailing Address - Street 1:246 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3356
Mailing Address - Country:US
Mailing Address - Phone:208-234-4100
Mailing Address - Fax:208-234-4192
Practice Address - Street 1:246 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3356
Practice Address - Country:US
Practice Address - Phone:208-234-4100
Practice Address - Fax:208-234-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1074550001Medicare NSC
ID1375600Medicare PIN