Provider Demographics
NPI:1841216009
Name:ISSUREE, RAJCOOMAR (RPT)
Entity Type:Individual
Prefix:
First Name:RAJCOOMAR
Middle Name:
Last Name:ISSUREE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 W EMERALD ST STE 195
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8296
Mailing Address - Country:US
Mailing Address - Phone:208-376-7313
Mailing Address - Fax:208-376-7487
Practice Address - Street 1:8950 W EMERALD ST
Practice Address - Street 2:SUITE #195
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4854
Practice Address - Country:US
Practice Address - Phone:208-376-7313
Practice Address - Fax:208-376-7487
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806834400Medicaid
IDTD767OtherBLUE CROSS OF ID
ID000010138628OtherREGENCE BLUE SHIELD OF ID
16543362Medicare UPIN