Provider Demographics
NPI:1558375477
Name:IDEEN, DANA RAY (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:RAY
Last Name:IDEEN
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 1:1315 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2212
Mailing Address - Country:US
Mailing Address - Phone:307-235-8552
Mailing Address - Fax:307-235-4656
Practice Address - Street 1:1315 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2212
Practice Address - Country:US
Practice Address - Phone:307-235-8552
Practice Address - Fax:307-235-4656
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3742A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104037500Medicaid
WYE14839Medicare UPIN
WY104037500Medicaid