Provider Demographics
NPI:1952469082
Name:KATOVICH, JOHN RICHARD JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:KATOVICH
Suffix:JR
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:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861
Mailing Address - Country:US
Mailing Address - Phone:208-689-3577
Mailing Address - Fax:
Practice Address - Street 1:229 S 7TH STREET
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861
Practice Address - Country:US
Practice Address - Phone:208-245-5551
Practice Address - Fax:208-245-9303
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4923207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010003875OtherREGENCE
ID4923-9OtherBC
E04223Medicare UPIN
1118097Medicare ID - Type Unspecified