Healthcare Provider Details

I. General information

NPI: 1164861340
Provider Name (Legal Business Name): MELISSA KJOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-4700
  • Fax: 208-282-4696
Mailing address:
  • Phone: 208-251-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRM-1348
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: