Healthcare Provider Details

I. General information

NPI: 1174783401
Provider Name (Legal Business Name): JONATHAN DAVID DEBOOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W IRONWOOD DR STE 250
COEUR D ALENE ID
83814-1415
US

IV. Provider business mailing address

PO BOX 35145 #40023
SEATTLE WA
98124-5145
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-8585
  • Fax: 425-407-1112
Mailing address:
  • Phone: 425-407-1500
  • Fax: 425-407-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA107920
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-13851
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: