Healthcare Provider Details

I. General information

NPI: 1487066643
Provider Name (Legal Business Name): JOSH SIRUCEK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1582 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1582 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-213-5256
  • Fax:
Mailing address:
  • Phone: 208-213-5256
  • Fax: 877-682-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO05204
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO208318
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: