Healthcare Provider Details

I. General information

NPI: 1144264011
Provider Name (Legal Business Name): BRYAN L DRAKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E LIBERTY ST
WEISER ID
83672-2261
US

IV. Provider business mailing address

360 E LIBERTY ST
WEISER ID
83672-2261
US

V. Phone/Fax

Practice location:
  • Phone: 208-414-1124
  • Fax: 208-414-0947
Mailing address:
  • Phone: 208-414-1124
  • Fax: 208-414-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-67
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: