Basic Information
| Provider Information | |||||||||
| NPI: | 1831119809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COX | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 W 2ND S | ||||||||
| Address2: | |||||||||
| City: | SODA SPRINGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832761568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 W 2ND S | ||||||||
| Address2: | |||||||||
| City: | SODA SPRINGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832761568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | RPT480 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | T4215 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |