Provider Demographics
NPI:1356630941
Name:BLANCHARD, JORDAN V (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:V
Last Name:BLANCHARD
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 1:645 E. 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672
Mailing Address - Country:US
Mailing Address - Phone:208-414-1124
Mailing Address - Fax:208-414-0947
Practice Address - Street 1:360 E. LIBERTY
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672
Practice Address - Country:US
Practice Address - Phone:208-414-1124
Practice Address - Fax:208-414-0947
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005733Medicare Oscar/Certification