Healthcare Provider Details

I. General information

NPI: 1790743490
Provider Name (Legal Business Name): JOHN BENJAMIN TRAUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 18TH AVE STE A
POCATELLO ID
83201-3358
US

IV. Provider business mailing address

PO BOX 4107
POCATELLO ID
83205-4107
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-7760
  • Fax: 208-232-1950
Mailing address:
  • Phone: 208-232-7760
  • Fax: 208-232-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-7587
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: