MEDICARE: DR. JONATHAN WALDEN HOUSLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	M-9862	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457382244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN WALDEN HOUSLEY MD

Provider Business Mailing Address
First Line	:	300 S 3RD W
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1559
Country	:	US
Telephone Number	:	208-547-3341
Fax Number	:	208-547-2790

Provider Business Practice Location Address
First Line	:	300 S 3RD W
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1559
Country	:	US
Telephone Number	:	208-547-4961
Fax Number	:	208-547-3781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	10/12/2022

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