Provider Demographics
NPI:1942229570
Name:NATHAN, RICHARD ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:NATHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7573
Mailing Address - Country:US
Mailing Address - Phone:208-535-8400
Mailing Address - Fax:208-535-8409
Practice Address - Street 1:3614 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-535-8400
Practice Address - Fax:208-535-8409
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-301207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806522000Medicaid
ID1302646Medicare PIN
ID806522000Medicaid