Healthcare Provider Details

I. General information

NPI: 1972537892
Provider Name (Legal Business Name): JAY ROBERT MCMASTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 N 2ND E
REXBURG ID
83440-1638
US

IV. Provider business mailing address

256 N 2ND E
REXBURG ID
83440-1638
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-9646
  • Fax: 208-656-9645
Mailing address:
  • Phone: 208-656-9646
  • Fax: 208-656-9645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberO-0409
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberO-0409
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: