Provider Demographics
NPI:1275698367
Name:BURRY, JEFFREY DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DANIEL
Last Name:BURRY
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 1:330 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-746-0193
Mailing Address - Fax:208-746-7074
Practice Address - Street 1:330 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-746-0193
Practice Address - Fax:208-746-7074
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001929207Y00000X
IDO-337207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8398166Medicaid
000010147208OtherREGENCE BLUESHIELD OF ID
55098OtherBLUECROSS OF IDAHO
ID806910700Medicaid
000010147208OtherREGENCE BLUESHIELD OF ID
ID1302895Medicare ID - Type Unspecified
ID806910700Medicaid
P00154348Medicare ID - Type UnspecifiedRAILROAD MEDICARE