Provider Demographics
NPI:1336138817
Name:CLARKE, DAVID MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 N MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-6925
Mailing Address - Country:US
Mailing Address - Phone:208-376-4940
Mailing Address - Fax:208-376-6812
Practice Address - Street 1:1675 N MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-6925
Practice Address - Country:US
Practice Address - Phone:208-376-4940
Practice Address - Fax:208-376-6812
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC378111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010151977OtherBLUE SHIELD
IDC3787OtherBLUE CROSS OF IDAHO
ID000010151977OtherBLUE SHIELD