Provider Demographics
NPI:1578591210
Name:GOLTRY, BRIAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:GOLTRY
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-323-0031
Mailing Address - Fax:208-323-0064
Practice Address - Street 1:2347 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4881
Practice Address - Country:US
Practice Address - Phone:208-323-0031
Practice Address - Fax:208-323-0064
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7838207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000313Medicare PIN