Healthcare Provider Details

I. General information

NPI: 1104867662
Provider Name (Legal Business Name): JACK C CHAFFIN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 9589
BOISE ID
83707-4589
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2152
  • Fax:
Mailing address:
  • Phone: 208-472-8109
  • Fax: 208-472-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberM8872
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberM8872
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: