Provider Demographics
NPI:1932674553
Name:PRICE, RAYMOND DALE (PA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DALE
Last Name:PRICE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ALAN ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5801
Mailing Address - Country:US
Mailing Address - Phone:208-528-7655
Mailing Address - Fax:
Practice Address - Street 1:2100 ALAN ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5801
Practice Address - Country:US
Practice Address - Phone:208-528-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine