Provider Demographics
NPI:1457382244
Name:HOUSLEY, JONATHAN WALDEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WALDEN
Last Name:HOUSLEY
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 1:300 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1559
Mailing Address - Country:US
Mailing Address - Phone:208-547-3341
Mailing Address - Fax:208-547-2790
Practice Address - Street 1:300 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1559
Practice Address - Country:US
Practice Address - Phone:208-547-4961
Practice Address - Fax:208-547-3781
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1285970582Medicaid
ID000010164638OtherBLUE SHIELD
ID000010164639OtherBLUE SHIELD
ID807879100Medicaid
ID820227163B044OtherTRI CARE
ID807879102Medicaid
ID807879101Medicaid
ID807879101Medicaid