Basic Information
| Provider Information | |||||||||
| NPI: | 1124001862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAIRS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836615420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086429376 | ||||||||
| FaxNumber: | 2086429376 | ||||||||
| Practice Location | |||||||||
| Address1: | 1219 SW 4TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979144516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418892229 | ||||||||
| FaxNumber: | 5418894378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | DO20644 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 804163300 | 05 | ID | MEDICAID |