Provider Demographics
NPI:1558654756
Name:THOME, CLINTON M (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:M
Last Name:THOME
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 1:1686 W RIVERSTONE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5779
Mailing Address - Country:US
Mailing Address - Phone:208-765-4807
Mailing Address - Fax:208-765-2903
Practice Address - Street 1:1686 W RIVERSTONE DR STE 1
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5779
Practice Address - Country:US
Practice Address - Phone:208-765-4807
Practice Address - Fax:866-573-0853
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13168207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345816801Medicaid
TX408325YK00Medicare PIN
ID11003641Medicare PIN
TX345816801Medicaid