Healthcare Provider Details

I. General information

NPI: 1457700262
Provider Name (Legal Business Name): TRAVIS CLYDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 W CHERRY LN STE 205
MERIDIAN ID
83642-8530
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3500
  • Fax: 208-302-3555
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-14185
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRM-1547
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-14185
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM-14185
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: