Healthcare Provider Details

I. General information

NPI: 1669340048
Provider Name (Legal Business Name): CLINIC 5C DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 N LAKEWOOD DR FL 3
COEUR D ALENE ID
83814-4928
US

IV. Provider business mailing address

1875 N LAKEWOOD DR FL 3
COEUR D ALENE ID
83814-4928
US

V. Phone/Fax

Practice location:
  • Phone: 509-343-0250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CAMERON CHESNUT
Title or Position: OWNER
Credential: MD
Phone: 509-343-0250