Basic Information
| Provider Information | |||||||||
| NPI: | 1942205604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYAJIAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3085 E MAGIC VIEW DR # 140 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836423757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339300 | ||||||||
| FaxNumber: | 2084339854 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 E MAGIC VIEW DR # 140 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836423757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339300 | ||||||||
| FaxNumber: | 2084339854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0602X | M6896 | ID | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207Y00000X | M6896 | ID | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 003581300 | 05 | ID | MEDICAID |