Provider Demographics
NPI:1003012204
Name:CLAIR, CHARLES MALCOLM JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MALCOLM
Last Name:CLAIR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5043
Mailing Address - Country:US
Mailing Address - Phone:208-436-0481
Mailing Address - Fax:
Practice Address - Street 1:1071 RENEE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2508
Practice Address - Country:US
Practice Address - Phone:208-252-5602
Practice Address - Fax:208-269-7094
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10525208M00000X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11479847OtherAAMC ID