Provider Demographics
NPI:1306880844
Name:PEARCE, JOHN R (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PEARCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 S KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4828
Mailing Address - Country:US
Mailing Address - Phone:208-455-3545
Mailing Address - Fax:208-454-9690
Practice Address - Street 1:1825 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4828
Practice Address - Country:US
Practice Address - Phone:208-455-3545
Practice Address - Fax:208-454-9690
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806342000Medicaid
H64970Medicare UPIN
ID806342000Medicaid
P00268215Medicare PIN