Healthcare Provider Details

I. General information

NPI: 1417397001
Provider Name (Legal Business Name): JOSEPH JAMES KRAKKER III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S DAISY ST
SALMON ID
83467-4709
US

IV. Provider business mailing address

203 S DAISY ST
SALMON ID
83467-4709
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-6212
  • Fax: 888-789-1866
Mailing address:
  • Phone: 208-756-5600
  • Fax: 888-789-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7858
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0946
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: