Provider Demographics
NPI:1366731259
Name:JENSEN-OTSU, ELSBETH CHIYO (MD)
Entity type:Individual
Prefix:
First Name:ELSBETH
Middle Name:CHIYO
Last Name:JENSEN-OTSU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST.
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1315
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1315
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14213207RG0100X
CO53498207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program