Healthcare Provider Details

I. General information

NPI: 1457382723
Provider Name (Legal Business Name): JONATHAN V. GILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 E LOUISE DR SUITE 400
MERIDIAN ID
83642-5047
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-364-3000
  • Fax: 208-364-3191
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM8195
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: