Provider Demographics
NPI:1790988509
Name:MULERT, JEFFREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:MULERT
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:2550 ADDISON AVE E
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6749
Practice Address - Country:US
Practice Address - Phone:208-814-7700
Practice Address - Fax:208-933-9301
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10252208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790988509Medicaid
ID808166700Medicaid
ID1100382Medicare PIN