Healthcare Provider Details

I. General information

NPI: 1265637573
Provider Name (Legal Business Name): JEFFREY D HANCOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 WALKER DR
REXBURG ID
83440-1657
US

IV. Provider business mailing address

1707 W 2175 S
SYRACUSE UT
84075-8565
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9559
  • Fax:
Mailing address:
  • Phone: 801-725-0280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5755112-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: