Provider Demographics
NPI:1932417607
Name:JULIAN DEBRUYNKOPS MD PA
Entity Type:Organization
Organization Name:JULIAN DEBRUYNKOPS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE BRUYN KOPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-6106
Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-6106
Mailing Address - Fax:
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-6106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1109531Medicare Oscar/Certification
IDC36818Medicare UPIN