Provider Demographics
NPI:1114947389
Name:BLAIR, RONALD WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WILLIAM
Last Name:BLAIR
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-811-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 212
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8400
Practice Address - Fax:208-734-3045
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-488208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808052500Medicaid
IDP00973592OtherMCRR
ID808052500Medicaid