Provider Demographics
NPI:1912091174
Name:MUTO, JOHN HOWARD (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HOWARD
Last Name:MUTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3503
Mailing Address - Country:US
Mailing Address - Phone:208-384-9194
Mailing Address - Fax:208-384-9327
Practice Address - Street 1:1175 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3503
Practice Address - Country:US
Practice Address - Phone:208-384-9194
Practice Address - Fax:208-384-9327
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002597500Medicaid
ID0169660001Medicare NSC
ID1591150Medicare PIN
IDT44329Medicare UPIN