Provider Demographics
NPI:1306862792
Name:IPPOLITO, JOSEPH W JR (MD)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:W
Last Name:IPPOLITO
Suffix:JR
Gender:M
Credentials:MD
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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:83301-5050
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:83301-6050
Practice Address - Country:US
Practice Address - Phone:208-736-7620
Practice Address - Fax:208-735-9537
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2021-11-23
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Provider Licenses
StateLicense IDTaxonomies
IDM7008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001696OtherREGENCE BLUE SHIELD OF ID
IDDY066OtherBLUE CROSS OF IDAHO
ID003755600Medicaid
ID003755600Medicaid
ID1134549Medicare PIN