Provider Demographics
NPI:1043225543
Name:CHESNUTT, JAMES CLIVE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CLIVE
Last Name:CHESNUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL
Mailing Address - Street 2:STE 210
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-449-1146
Practice Address - Street 1:4811 MEADOWS RD STE 101
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2542
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-449-1146
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD19344207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074666Medicaid
G08090Medicare UPIN