Healthcare Provider Details

I. General information

NPI: 1316981632
Provider Name (Legal Business Name): JEAN U BENDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6273
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7336
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM9028
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: