Provider Demographics
NPI:1396188751
Name:WYNN, DONRAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DONRAPHAEL
Middle Name:
Last Name:WYNN
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-4200
Mailing Address - Fax:208-302-4255
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:STE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-4200
Practice Address - Fax:208-302-4255
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9164199-1205207W00000X, 207WX0109X
IDM-144032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology