Healthcare Provider Details

I. General information

NPI: 1265544894
Provider Name (Legal Business Name): JULIE S KIKUCHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E FORT ST
BOISE ID
83712-6322
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-2525
  • Fax: 208-375-2217
Mailing address:
  • Phone: 208-367-6030
  • Fax: 208-367-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberM9466
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-9466
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: