Provider Demographics
NPI:1497897458
Name:RAWLINGS, JODY BOYD (P T)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:BOYD
Last Name:RAWLINGS
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N 2ND EAST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1621
Mailing Address - Country:US
Mailing Address - Phone:208-359-6127
Mailing Address - Fax:208-359-9479
Practice Address - Street 1:217 N 2ND EAST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1621
Practice Address - Country:US
Practice Address - Phone:208-359-6127
Practice Address - Fax:208-359-9479
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 1346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
185556100OtherU.S. DEPT OF LABOR
650015362OtherRAILROAD MEDICARE
IDT3860OtherBLUE CROSS
ID000010020600OtherREGENCE BLUE SHIELD
WY1210564Medicaid
ID805399800Medicaid
ID000010020600OtherREGENCE BLUE SHIELD