Provider Demographics
NPI:1497795215
Name:REA, TED (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:REA
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 1:1411 FALLS AVE E
Mailing Address - Street 2:STE 1151
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-732-3030
Mailing Address - Fax:208-733-8970
Practice Address - Street 1:1411 FALLS AVE E
Practice Address - Street 2:STE 1151
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3455
Practice Address - Country:US
Practice Address - Phone:208-933-4277
Practice Address - Fax:208-933-4280
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6676207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002769900Medicaid
IDRR MEDICAREOther100016984