Provider Demographics
NPI:1144264011
Name:DRAKE, BRYAN L (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:L
Last Name:DRAKE
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 1:360 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2261
Mailing Address - Country:US
Mailing Address - Phone:208-414-1124
Mailing Address - Fax:208-414-0947
Practice Address - Street 1:360 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2261
Practice Address - Country:US
Practice Address - Phone:208-414-1124
Practice Address - Fax:208-414-0947
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-67207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002695400Medicaid
ID1300707OtherMEDICARE PART B
OR135457OtherMEDICARE PART B
ID002695400Medicaid