Provider Demographics
NPI:1346341021
Name:JONES, RICHARD THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:JONES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 W 1ST S
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1810
Mailing Address - Country:US
Mailing Address - Phone:208-356-7585
Mailing Address - Fax:208-356-7566
Practice Address - Street 1:32 W 1ST S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1810
Practice Address - Country:US
Practice Address - Phone:208-356-7585
Practice Address - Fax:208-356-7566
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7553A207Q00000X
IDM-10078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807909700Medicaid
WY123432300Medicaid
ID807875400Medicaid
WY21651Medicare PIN
ID1100104Medicare PIN
WYI62301Medicare UPIN
ID807875400Medicaid
ID807909700Medicaid