Healthcare Provider Details

I. General information

NPI: 1366731259
Provider Name (Legal Business Name): ELSBETH CHIYO JENSEN-OTSU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. FORT ST. # 111
BOISE ID
83702
US

IV. Provider business mailing address

500 W. FORT ST. # 111
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1315
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-422-1315
  • Fax: 208-422-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53498
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberM-14213
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: