Provider Demographics
NPI:1821090762
Name:FOX, JOHN STEPHEN (MD,)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:FOX
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 1:1545 E LEIGHFIELD DR
Mailing Address - Street 2:STE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5371
Mailing Address - Country:US
Mailing Address - Phone:208-855-2170
Mailing Address - Fax:
Practice Address - Street 1:1545 E LEIGHFIELD DR
Practice Address - Street 2:STE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5371
Practice Address - Country:US
Practice Address - Phone:208-955-8215
Practice Address - Fax:208-445-5899
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022842174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB17771Medicare ID - Type UnspecifiedFOX PROVIDER ID#
WAAB17770Medicare ID - Type UnspecifiedMC GROUP#
WACH4263Medicare ID - Type UnspecifiedRRMC GROUP#
WAA07184Medicare UPIN
WA160051046Medicare ID - Type UnspecifiedFOX RRMC PROVIDER#