Healthcare Provider Details

I. General information

NPI: 1114975802
Provider Name (Legal Business Name): JOHN ULLERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST SUITE 101
BOISE ID
83712-6273
US

IV. Provider business mailing address

305 E JEFFERSON ST SUITE 101
BOISE ID
83712-6273
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-0715
  • Fax: 208-345-1142
Mailing address:
  • Phone: 208-345-0715
  • Fax: 208-345-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-3962
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: