Provider Demographics
NPI:1669676276
Name:S. JEFF BRAY, DPM, INC.
Entity Type:Organization
Organization Name:S. JEFF BRAY, DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S
Authorized Official - Middle Name:JEFF
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-233-2100
Mailing Address - Street 1:2240 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2600
Mailing Address - Country:US
Mailing Address - Phone:208-233-2100
Mailing Address - Fax:208-233-3146
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2600
Practice Address - Country:US
Practice Address - Phone:208-233-2100
Practice Address - Fax:208-233-3146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP157213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD9805OtherRAILROAD MEDICARE
ID000010034464OtherBLUE SHIELD
IDP9364OtherBLUE CROSS
ID806125200Medicaid
ID6238280001Medicare NSC
IDP9364OtherBLUE CROSS
DD9805OtherRAILROAD MEDICARE