Provider Demographics
NPI:1063563823
Name:TRAYNOR, MATTHEW P (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:TRAYNOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4951
Mailing Address - Country:US
Mailing Address - Phone:208-529-6600
Mailing Address - Fax:208-529-6602
Practice Address - Street 1:2100 PROVIDENCE WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-6600
Practice Address - Fax:208-529-6602
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10686207W00000X, 207WX0009X
OK24632207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808405700Medicaid
ID808405700Medicaid