Healthcare Provider Details

I. General information

NPI: 1043225543
Provider Name (Legal Business Name): JAMES CLIVE CHESNUTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 MEADOWS RD STE 101
LAKE OSWEGO OR
97035-2542
US

IV. Provider business mailing address

200 NE MOTHER JOSEPH PL STE 210
VANCOUVER WA
98664-3295
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-6161
  • Fax: 360-449-1146
Mailing address:
  • Phone: 360-254-6161
  • Fax: 360-449-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD19344
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: