Provider Demographics
NPI:1427153097
Name:PATTERSON, TEMP RAY (MD)
Entity type:Individual
Prefix:
First Name:TEMP
Middle Name:RAY
Last Name:PATTERSON
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 1:1338 HILAND AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1561
Mailing Address - Country:US
Mailing Address - Phone:208-878-4197
Mailing Address - Fax:208-878-3638
Practice Address - Street 1:1338 HILAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1561
Practice Address - Country:US
Practice Address - Phone:208-878-4197
Practice Address - Fax:208-878-3638
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7021207Y00000X
HI13766207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001930OtherBLUE SHIELD
ID70219OtherBLUE CROSS
ID002796900Medicaid
1134683Medicare ID - Type Unspecified
G27434Medicare UPIN