Provider Demographics
NPI:1033262183
Name:MAYES, DARYL DEAN (PT, DPT, MHS)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:DEAN
Last Name:MAYES
Suffix:
Gender:M
Credentials:PT, DPT, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1976 S LINCOLN AVE
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6150
Mailing Address - Country:US
Mailing Address - Phone:208-644-1433
Mailing Address - Fax:208-644-1434
Practice Address - Street 1:1976 S LINCOLN AVE
Practice Address - Street 2:SUITE 6A
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6150
Practice Address - Country:US
Practice Address - Phone:208-644-1433
Practice Address - Fax:208-644-1434
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0044033Medicaid
ID1002857OtherSTATE INSURANCE FUND
ID1225235039OtherGROUP NPI
IDT2797OtherBLUE CROSS
ID322212OtherBLUE SHIELD
IDT2797OtherBLUE CROSS
ID0044033Medicaid