=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992807085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBIN JACKSON DELEON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W FORT ST PM&R, BOISE VA MEDICAL CENTER
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-422-1368
-----------------------------------------------------
Fax | 208-422-1188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8061 S DIEGO WAY
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-7378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | M-9583
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------