Provider Demographics
NPI:1265544894
Name:KIKUCHI, JULIE S (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:S
Last Name:KIKUCHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-367-6030
Mailing Address - Fax:208-367-6123
Practice Address - Street 1:121 E FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6322
Practice Address - Country:US
Practice Address - Phone:208-514-2525
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM94662080A0000X
IDM-9466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807362700Medicaid
ID807362700Medicaid