Basic Information
| Provider Information | |||||||||
| NPI: | 1003012204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAIR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MALCOLM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1322 STONERIDGE DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084360481 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1071 RENEE AVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082525602 | ||||||||
| FaxNumber: | 2082697094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | M-10525 | ID | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | M-10525 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11479847 | 01 | AAMC ID | OTHER |