Individual
RICHARD M MAYNARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
110 VISTA DR, POCATELLO, ID 83201-5824
(208) 234-2300
(208) 234-0026
Mailing address
110 VISTA DR, POCATELLO, ID 83201-5824
(208) 234-2300
(208) 234-0026
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
O-93
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010003340
BLUE SHIELD PROVIDER NUMB
ID
05
—
002665300
—
ID
01
—
080179525
RAILROAD MEDICARE NUMBER
ID
01
—
DV104
BLUE CROSS PROVIDER NUMBE
ID
Enumeration date
09/02/2005
Last updated
02/06/2014
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