Provider Demographics
NPI:1821156365
Name:DUBOSE, RICHARD ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-1128
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:208-489-4015
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4016
Practice Address - Fax:208-489-4015
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7865208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005570OtherBLUE SHIELD OF IDAHO
ID1821156365Medicaid
ID185570800OtherUS DEPT OF LABOR AND IND
ID57430OtherBLUE CROSS OF IDAHO
ID1821156365Medicaid
ID185570800OtherUS DEPT OF LABOR AND IND