Basic Information
| Provider Information | |||||||||
| NPI: | 1306862792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IPPOLITO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 SHOUP AVE W | ||||||||
| Address2: | SUITE F | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367620 | ||||||||
| FaxNumber: | 2087359537 | ||||||||
| Practice Location | |||||||||
| Address1: | 526 SHOUP AVE W | ||||||||
| Address2: | SUITE F | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367620 | ||||||||
| FaxNumber: | 2087359537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M7008 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000010001696 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | DY066 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | 003755600 | 05 | ID | MEDICAID |