Provider Demographics
NPI:1265026660
Name:IDEMA, JOHN PETER (BC-HIS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
Last Name:IDEMA
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S RIVER ST STE B
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8436
Mailing Address - Country:US
Mailing Address - Phone:208-788-0296
Mailing Address - Fax:208-994-0897
Practice Address - Street 1:221 S RIVER ST STE B
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8436
Practice Address - Country:US
Practice Address - Phone:208-788-0296
Practice Address - Fax:208-994-0897
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-2962237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty