Provider Demographics
NPI:1700835790
Name:TENLEY, CLIFFORD L (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:L
Last Name:TENLEY
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-4100
Mailing Address - Fax:208-381-4101
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:STE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:208-381-4101
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6335207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000414Medicare PIN