Provider Demographics
NPI:1881648251
Name:KATTENHORN, JON R (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:KATTENHORN
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-1200
Mailing Address - Fax:208-302-1255
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-302-1200
Practice Address - Fax:208-302-1255
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3893207V00000X
IDM-3893207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005174OtherBLUE SHIELD
ID003785900Medicaid
ID38935OtherBLUE CROSS
D93685Medicare UPIN
ID003785900Medicaid