Provider Demographics
NPI:1952592404
Name:DEVRIES, JASON B (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 16820
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83715-6820
Mailing Address - Country:US
Mailing Address - Phone:208-734-8441
Mailing Address - Fax:208-733-3881
Practice Address - Street 1:191 ADDISON AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5177
Practice Address - Country:US
Practice Address - Phone:208-734-8441
Practice Address - Fax:208-733-3881
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-196213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4935700001Medicare NSC