Healthcare Provider Details

I. General information

NPI: 1417241597
Provider Name (Legal Business Name): JONATHAN MOORE SHUPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LINCOLN WAY 315
COEUR D ALENE ID
83814-2527
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6000
  • Fax: 208-625-6001
Mailing address:
  • Phone: 208-625-5085
  • Fax: 208-625-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM12445
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: