Healthcare Provider Details

I. General information

NPI: 1083545735
Provider Name (Legal Business Name): IAN THOMAS O'CONNOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E ELGIN ST
CALDWELL ID
83605-3439
US

IV. Provider business mailing address

1411 E ELGIN ST
CALDWELL ID
83605-3439
US

V. Phone/Fax

Practice location:
  • Phone: 208-995-0641
  • Fax:
Mailing address:
  • Phone: 208-995-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7381817
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: