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NPI Code Detail

MEDICARE: CLARK R DAINES MD

MEDICARE: CLARK R DAINES MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207ZP0102XAnatomic Pathology & Clinical Pathology PhysicianM11914ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1M11914OTHERIDSTATE LICENSE
279892OTHERIDBLUE CROSS IDAHO

General Provider Information

NPI Number : 1144264045
Entity Type Code : Individual
Provider Name (Legal Business Name) : CLARK R DAINES MD
Provider Business Mailing Address
First Line : 1820 E 17TH ST
Second Line : STE 230
City : IDAHO FALLS
State : ID
Zip : 83404-6469
Country : US
Telephone Number : 208-529-9779
Fax Number : 208-542-2756
Provider Business Practice Location Address
First Line : 3100 CHANNING WAY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7533
Country : US
Telephone Number : 208-529-6050
Fax Number : 208-529-7085
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2006
Last Update Date : 06/16/2014

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