Healthcare Provider Details

I. General information

NPI: 1578782496
Provider Name (Legal Business Name): PAUL W. JOHNS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 FREMONT AVE
IDAHO FALLS ID
83402-1510
US

IV. Provider business mailing address

365 N 200 W
BLACKFOOT ID
83221-5757
US

V. Phone/Fax

Practice location:
  • Phone: 208-526-0404
  • Fax:
Mailing address:
  • Phone: 208-785-6309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberM-4536
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: