Provider Demographics
NPI:1194715136
Name:HLAVINKA, JON L (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:L
Last Name:HLAVINKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6207
Mailing Address - Country:US
Mailing Address - Phone:208-342-7400
Mailing Address - Fax:208-342-1879
Practice Address - Street 1:300 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-342-7400
Practice Address - Fax:208-342-7400
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002364500Medicaid
ID105443OtherBLUE CROSS
ID000010004642OtherBLUE SHIELD
ID806359300OtherHEALTHY CONNECTIONS
ID080037810Medicare ID - Type UnspecifiedRAILROAD
C96887Medicare UPIN
ID002364500Medicaid