Healthcare Provider Details

I. General information

NPI: 1669676276
Provider Name (Legal Business Name): S. JEFF BRAY, DPM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax: 208-233-3146
Mailing address:
  • Phone: 208-233-2100
  • Fax: 208-233-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP157
License Number StateID

VIII. Authorized Official

Name: DR. S JEFF BRAY
Title or Position: PRESIDENT
Credential: DPM
Phone: 208-233-2100