Provider Demographics
NPI:1437346483
Name:RAINEY, PHILIP DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DAVID
Last Name:RAINEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 N DUNBARTON PL
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5681
Mailing Address - Country:US
Mailing Address - Phone:208-514-6405
Mailing Address - Fax:208-955-2735
Practice Address - Street 1:2051 S COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2815
Practice Address - Country:US
Practice Address - Phone:208-672-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0799974Medicaid