Provider Demographics
NPI:1326152927
Name:PRINCE, CLAY CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:CHRISTIAN
Last Name:PRINCE
Suffix:
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 1:10 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2058
Mailing Address - Country:US
Mailing Address - Phone:208-656-9467
Mailing Address - Fax:208-656-9466
Practice Address - Street 1:10 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2058
Practice Address - Country:US
Practice Address - Phone:208-656-9467
Practice Address - Fax:208-656-9466
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806946300Medicaid
1103061Medicare PIN
H74630Medicare UPIN