Provider Demographics
NPI:1164570172
Name:DANFORTH, REBECCA L (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:DANFORTH
Suffix:
Gender:F
Credentials:MD
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 7609
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7609
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:406-329-7547
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:406-329-7547
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12452207RR0500X, 207RR0500X
WYTL2221207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164570172Medicaid