Provider Demographics
NPI:1902139066
Name:REIS, LAURA THALIA (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:THALIA
Last Name:REIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ARNHEIM
Other - Last Name:DANIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1399
Mailing Address - Fax:
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:208-463-3046
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4513207Q00000X, 204D00000X
IDO-0889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA219640030Medicare PIN
ID20008632Medicare PIN