Provider Demographics
NPI:1902952930
Name:WRAY, ADAM (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:WRAY
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 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-785-4100
Mailing Address - Fax:
Practice Address - Street 1:326 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1741
Practice Address - Country:US
Practice Address - Phone:208-785-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0444207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS6117OtherBLUE CROSS POC
ID000010163015OtherREGENCE BLUE SHIELD BLKFT
ID000010163016OtherREGENCE BLUE SHIELD POC
ID315520OtherALTIUS
IDS6116OtherBLUE CROSS BLKFT
ID315520OtherALTIUS
I25192Medicare UPIN