Provider Demographics
NPI:1851400956
Name:RAYBURN, ROBERT LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS
Last Name:RAYBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540556
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0556
Mailing Address - Country:US
Mailing Address - Phone:801-363-1445
Mailing Address - Fax:801-596-2812
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-993-9551
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161957-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2000040OtherUNITED HEALTHCARE
UTPR00955OtherMOLINA
UT2359OtherHEALTHY U
UT416954OtherDESERET MUTUAL
UT107006359101OtherIHC
UT7539OtherPEHP
UTQM0000049540OtherALTIUS
UT870280408RA1OtherEDUCATORS MUTUAL
MT401765Medicaid
AZ284068Medicaid
UTC63923Medicare UPIN