Provider Demographics
NPI:1861440513
Name:HANSON, RAY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:WILLIAM
Last Name:HANSON
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 3568
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3568
Mailing Address - Country:US
Mailing Address - Phone:208-552-8573
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9006208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB4851OtherBLUE CROSS OLD
IDHB399OtherBLUE CROSS
ID313058OtherALTIUS
ID807127000Medicaid
IDHB399OtherBLUE CROSS
ID807127000Medicaid
IDA41911Medicare UPIN
IDB4851OtherBLUE CROSS OLD
IDP00222304Medicare PIN