Healthcare Provider Details

I. General information

NPI: 1275698367
Provider Name (Legal Business Name): JEFFREY DANIEL BURRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 WARNER DR
LEWISTON ID
83501-4441
US

IV. Provider business mailing address

330 WARNER DR
LEWISTON ID
83501-4441
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-0193
  • Fax: 208-746-7074
Mailing address:
  • Phone: 208-746-0193
  • Fax: 208-746-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberOP00001929
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberO-337
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: