Healthcare Provider Details

I. General information

NPI: 1194715136
Provider Name (Legal Business Name): JON L HLAVINKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E BANNOCK ST
BOISE ID
83712-6207
US

IV. Provider business mailing address

300 E BANNOCK ST
BOISE ID
83712-6207
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-7400
  • Fax: 208-342-7400
Mailing address:
  • Phone: 208-342-7400
  • Fax: 208-342-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6008
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: