Provider Demographics
NPI:1396862033
Name:OBRAY, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:OBRAY
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 1:296 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1561
Mailing Address - Country:US
Mailing Address - Phone:208-547-2779
Mailing Address - Fax:208-547-4910
Practice Address - Street 1:296 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1561
Practice Address - Country:US
Practice Address - Phone:208-547-2779
Practice Address - Fax:208-547-4910
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3806208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005790OtherREGENCE BLUE SHIELD IDAHO
ID38067OtherBLUE CROSS OF IDAHO
ID1112403Medicare ID - Type Unspecified
ID000010005790OtherREGENCE BLUE SHIELD IDAHO