Provider Demographics
NPI:1154561116
Name:JOSEPH W IPPOLITO JR MD PLLC
Entity type:Organization
Organization Name:JOSEPH W IPPOLITO JR MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:IPPOLITO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:208-736-7620
Mailing Address - Street 1:526 SHOUP AVE W
Mailing Address - Street 2:SUITE F
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4591
Mailing Address - Country:US
Mailing Address - Phone:208-736-7620
Mailing Address - Fax:208-735-9537
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:SUITE F
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4591
Practice Address - Country:US
Practice Address - Phone:208-736-7620
Practice Address - Fax:208-735-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7008305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001696OtherREGENCE BLUE SHIELD OF IDAHO
IDDY066OtherBLUE CROSS OF IDAHO
ID003755600Medicaid
ID003755600Medicaid