Healthcare Provider Details

I. General information

NPI: 1306880844
Provider Name (Legal Business Name): JOHN R PEARCE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 S KIMBALL AVE
CALDWELL ID
83605-4828
US

IV. Provider business mailing address

1825 S KIMBALL AVE
CALDWELL ID
83605-4828
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-3545
  • Fax: 208-454-9690
Mailing address:
  • Phone: 208-455-3545
  • Fax: 208-454-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO283
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: