Provider Demographics
NPI:1013064641
Name:LIVINGSTON, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5148208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000192OtherREGENCE BLUE SHIELD OF ID
BL1428499OtherDEA
1120497Medicare ID - Type Unspecified
C47918Medicare UPIN