Basic Information
| Provider Information | |||||||||
| NPI: | 1578523577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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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 | 207P00000X | OP00001738 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | O-272 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1578523577 | 05 | ID | MEDICAID | 806111700 | 05 | ID | MEDICAID | 1578523577 | 05 | MT | MEDICAID | 1578523577 | 05 | WA | MEDICAID |