Provider Demographics
NPI:1386685493
Name:RAY, DAVID S (MPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:RAY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 E GENTRY WAY
Mailing Address - Street 2:STE 250
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3501
Mailing Address - Country:US
Mailing Address - Phone:208-888-0044
Mailing Address - Fax:
Practice Address - Street 1:1175 E PARKCENTER BLVD
Practice Address - Street 2:STE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6751
Practice Address - Country:US
Practice Address - Phone:208-367-1010
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652048Medicare ID - Type Unspecified