Basic Information
| Provider Information | |||||||||
| NPI: | 1649253188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUGHAN | ||||||||
| FirstName: | DELRAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13900 W WAINWRIGHT DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837135028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Practice Location | |||||||||
| Address1: | 13900 W WAINWRIGHT DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837135028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089385823 | ||||||||
| FaxNumber: | 2089385306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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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 | 207Y00000X | M4908 | ID | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 002592700 | 05 | ID | MEDICAID |