Healthcare Provider Details

I. General information

NPI: 1114910296
Provider Name (Legal Business Name): MELVIN TERRY JEPPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date: 04/03/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

1501 HILAND AVE SUITE B
BURLEY ID
83318-2682
US

IV. Provider business mailing address

1501 HILAND AVE SUITE B1
BURLEY ID
83318-2682
US

V. Phone/Fax

Practice location:
  • Phone: 208-878-2229
  • Fax: 208-878-4599
Mailing address:
  • Phone: 208-878-2229
  • Fax: 208-878-4599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM5646
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: