Provider Demographics
NPI:1497893366
Name:ANSCHUTZ, TRAVIS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:WAYNE
Last Name:ANSCHUTZ
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 1:3100 CHANNING WAY # 100
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7533
Mailing Address - Country:US
Mailing Address - Phone:208-535-4575
Mailing Address - Fax:208-535-4569
Practice Address - Street 1:3000 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3217
Practice Address - Country:US
Practice Address - Phone:479-553-1294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY391752080N0001X
IDM101022080N0001X
ARE-112272080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808012100Medicaid