Provider Demographics
NPI:1588727879
Name:GRIFFETH, WILLIAM BRENT
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRENT
Last Name:GRIFFETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6430
Mailing Address - Country:US
Mailing Address - Phone:208-529-3355
Mailing Address - Fax:208-529-9581
Practice Address - Street 1:2037 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6430
Practice Address - Country:US
Practice Address - Phone:208-529-3355
Practice Address - Fax:208-529-9581
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDW0673OtherBLUE CROSS
ID000010022488OtherBLUE SHIELD
ID1655237Medicare ID - Type Unspecified