Basic Information
| Provider Information | |||||||||
| NPI: | 1104867662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAFFIN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9589 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728109 | ||||||||
| FaxNumber: | 2084728172 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672152 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | M8872 | ID | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | M8872 | ID | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 806728500 | 05 | ID | MEDICAID |