Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | M5148 | ID |
Y | 208600000X | Surgeon | M5148 | ID |
NPI | 1013064641 |
---|---|
Provider Name | John M Livingston |
First Address | Boise, ID 83704-4831 |
Second Address | Boise, ID 83704-4831 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010000192 | REGENCE BLUE SHIELD OF ID (01) | ID |
BL1428499 | DEA (01) | |
C47918 | (02) |