Basic Information
| Provider Information | |||||||||
| NPI: | 1821090762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1545 E LEIGHFIELD DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836465371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088552170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1545 E LEIGHFIELD DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836465371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089558215 | ||||||||
| FaxNumber: | 2084455899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00022842 | WA | Y | Other Service Providers | Specialist |
No ID Information.