Provider Demographics
NPI:1922059500
Name:AJAX, TED J (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:J
Last Name:AJAX
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 3451
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3451
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-252-2662
Practice Address - Street 1:732 LINDSAY LN
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4103
Practice Address - Country:US
Practice Address - Phone:307-587-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6488A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115651900Medicaid
WYE75345Medicare UPIN
WY310547Medicare ID - Type UnspecifiedANESTHESOLOGIST