Provider Demographics
NPI:1144321753
Name:LOFGRAN, REID WAYNE (DO)
Entity type:Individual
Prefix:
First Name:REID
Middle Name:WAYNE
Last Name:LOFGRAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:134 W 4TH AVE
Mailing Address - Street 2:267 NORTH CANYON DR
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1248
Mailing Address - Country:US
Mailing Address - Phone:208-934-4446
Mailing Address - Fax:208-934-4442
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:208-934-4442
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806777400Medicaid
ID1518377019OtherNORTH CANYON MEDICAL CENTER
ID806025500Medicaid
ID138520Medicare Oscar/Certification
ID806025500Medicaid