Provider Demographics
NPI:1104188457
Name:REDD, NEPHI ANDERSEN (DO)
Entity Type:Individual
Prefix:DR
First Name:NEPHI
Middle Name:ANDERSEN
Last Name:REDD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 S 25TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4606
Mailing Address - Country:US
Mailing Address - Phone:208-656-1500
Mailing Address - Fax:
Practice Address - Street 1:3320 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4606
Practice Address - Country:US
Practice Address - Phone:208-656-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN