Healthcare Provider Details

I. General information

NPI: 1144213554
Provider Name (Legal Business Name): JONATHAN CREE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

POCATELLO (ISU) FAMILY MEDICINE 465 MEMORIAL DRIVE
POCATELLO ID
83209-0001
US

IV. Provider business mailing address

POCATELLO (ISU) FAMILY MEDICINE 465 MEMORIAL DRIVE
POCATELLO ID
83209-0001
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-4700
  • Fax: 208-282-4696
Mailing address:
  • Phone: 208-282-4700
  • Fax: 208-282-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6974
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: