Provider Demographics
NPI:1831108455
Name:DOMARAD, WILLIAM K (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:K
Last Name:DOMARAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 E 65TH S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7662
Mailing Address - Country:US
Mailing Address - Phone:605-939-5526
Mailing Address - Fax:
Practice Address - Street 1:505 NE 87TH AVE STE 460
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1965
Practice Address - Country:US
Practice Address - Phone:360-514-7771
Practice Address - Fax:360-514-7769
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD73302084N0400X
IADO-043202084N0400X
IN02003790A2084N0400X
IDO-12912084N0600X
WAOP000019492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806992600Medicaid
ID000010148189OtherREGENCE BLUE SHIELD OF ID
IN201057130Medicaid
000000756863OtherANTHEM (REID PHYSICIAN ASSOCIATES, INC.)
IDS5247OtherBLUE CROSS OF IDAHO
OH0109759Medicaid
INM400066602Medicare PIN
OH0109759Medicaid
ID806992600Medicaid