Healthcare Provider Details

I. General information

NPI: 1689237752
Provider Name (Legal Business Name): COLBY RAY BROWER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440-1605
US

IV. Provider business mailing address

465 MEMORIAL DR
POCATELLO ID
83201-4098
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-5401
  • Fax:
Mailing address:
  • Phone: 208-234-4700
  • Fax: 208-282-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-15786
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: