Basic Information
Provider Information | |||||||||
NPI: | 1790743490 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRAUL | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4107 | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832054107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082327760 | ||||||||
FaxNumber: | 2082321950 | ||||||||
Practice Location | |||||||||
Address1: | 333 N 18TH AVE STE A | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832013358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082327760 | ||||||||
FaxNumber: | 2082321950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2006 | ||||||||
LastUpdateDate: | 08/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | M-7587 | ID | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 805209000 | 05 | ID |   | MEDICAID |