Provider Demographics
NPI:1457110298
Name:WRAY DERMATOLOGY
Entity type:Organization
Organization Name:WRAY DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-680-4219
Mailing Address - Street 1:326 POPLAR ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1741
Mailing Address - Country:US
Mailing Address - Phone:986-275-0003
Mailing Address - Fax:986-275-0005
Practice Address - Street 1:326 POPLAR ST STE 101
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1741
Practice Address - Country:US
Practice Address - Phone:986-275-0003
Practice Address - Fax:986-275-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-14
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty