Provider Demographics
NPI:1629173760
Name:RAE, DONALD D (DC)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:D
Last Name:RAE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3503
Mailing Address - Country:US
Mailing Address - Phone:208-345-3630
Mailing Address - Fax:208-345-3640
Practice Address - Street 1:1149 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3503
Practice Address - Country:US
Practice Address - Phone:208-345-3630
Practice Address - Fax:208-345-3640
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC373111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC3779OtherBLUE CROSS
ID000010145978OtherBLUE SHIELD
IDC3779OtherBLUE CROSS
ID1671130Medicare ID - Type Unspecified