Provider Demographics
NPI:1447324116
Name:DESFOSSES, DANNY RAE (DPT)
Entity type:Individual
Prefix:
First Name:DANNY
Middle Name:RAE
Last Name:DESFOSSES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2844
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2844
Mailing Address - Country:US
Mailing Address - Phone:208-233-4800
Mailing Address - Fax:208-233-4887
Practice Address - Street 1:1033 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-233-4800
Practice Address - Fax:208-233-4887
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010008720OtherBLUE SHIELD
ID004399000Medicaid
IDT1559OtherBLUE CROSS
ID650008819OtherRAILROAD MEDICARE
ID1650368Medicare PIN