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Organization
IDAHO STATE UNIVERSITY
Active
Organization
IDAHO STATE UNIVERSITY
Active
Other names
Idaho State Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
JODI WOTOWEY (HEAD ATHLETIC TRAINER)
(208) 282-3408
Entity
Organization
Contact information
Practice address
921 S 8TH AVE STOP 8173, SPORTS AND ORTHOPAEDIC CENTER, POCATELLO, ID 83209-8173
(208) 282-3408
Mailing address
5050 SPRING VALLEY RD, DALLAS, TX 75244-3995
(800) 555-9073
(972) 367-3452
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
207QS0010X
Sports Medicine (Family Medicine) Physician
—
NULL
207QS0010X
Sports Medicine (Family Medicine) Physician
—
—
207X00000X
Orthopaedic Surgery Physician
—
NULL
207X00000X
Orthopaedic Surgery Physician
—
—
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
—
NULL
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
—
—
Other
Enumeration date
11/13/2014
Last updated
11/13/2014
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