Basic Information
Provider Information
NPI: 1003012204
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLAIR
FirstName: CHARLES
MiddleName: MALCOLM
NamePrefix:  
NameSuffix: JR.
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 05/06/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 05/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XM-10525IDY Allopathic & Osteopathic PhysiciansFamily Medicine 
208M00000XM-10525IDN Allopathic & Osteopathic PhysiciansHospitalist 

ID Information
IDTypeStateIssuerDescription
1147984701 AAMC IDOTHER


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