Basic Information
| Provider Information | |||||||||
| NPI: | 1578646345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNT | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21634 ANGEL POINT LN | ||||||||
| Address2: | |||||||||
| City: | PECK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835458045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084866063 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | CLEARWATER VALLEY HOSPITAL & CLINICS | ||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M-9739 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A4684 | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 5069 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 807606600 | 05 | ID | MEDICAID |